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PULMONARY 


TUBERCULOSIS 


BY 

MAURICE  FISHBERG,  M.D. 

CLINICAL  PROFESSOK  OF  TUBERCULOSIS,   NEW  YORK  UNIVERSITY    AND    BELLEVUE    HOSPITAL 

MEDICAL     college;    ATTENDING    PHYSICIAN,  MONTEFIORE    HOME    AND 

HOSPITAL  FOR  CHRONIC  DISEASES,    NEW  YORK 


ILLUSTRATED  WITH   91    ENGRAVINGS  AND    18   PLATES 


LEA   &   FEBIGER 

PHILADELPHIA   AND   NEW  YORK 


Entered  according  to  the  Act  of  Congress,  in  the  year  1916,  by 

LEA  &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


X^    :.\\ 


TO 

MY  WIFE 


PEEPACE. 


It  is  the  purpose  of  this  book  to  supply  the  general  practitioner 
with  information  concerning  the  etiology,  diagnosis,  prognosis  and 
treatment  of  pulmonary  tuberculosis,  its  clinical  forms  and  comnion 
complications.  An  experience  of  eighteen  years  with  the  tuberculosis 
problems  in  New  York  City  has  convinced  the  author  that:  (1)  The 
physician  can,  and  should,  do  more  than  recognize  phthisis  in  its 
earliest,  or  pretuberculous,  stage  and  at  once  send  him  to  a  sanatorium. 
(2)  That  ''incipient"  does  not  always  mean  curable  tuberculosis,  and 
conversely,  that  "advanced"  disease  does  not  necessarily  indicate  a 
hopeless  outlook.  (3)  That  institutional  treatment  is  not  the  only 
effective  method  of  handling  the  phthisical  patient.  (4)  If  all  tuber- 
culous persons  in  this  country  would  consent  to  hospitalization,  the 
available  institutions  would  hardly  accommodate  ten  per  cent,  of 
eligible  patients.  (5)  Even  those  treated  in  sanatoriums  must  be 
cared  for  by  their  family  physicians  before  admission  and  after  dis- 
charge. (6)  Careful  home  treatment  is  productive  of  practically  the 
same  immediate  and  ultimate  results  as  institutional  treatment,  and  is 
less  costly  to  the  patient  and  to  the  community. 

Recent  investigations  of  tuberculous  infection  have  radically  changed 
our  views  on  the  transmissibility  of  tuberculosis.  On  the  one  hand, 
it  was  found  that  patients  who  indiscriminately  expectorate  tubercle 
bacilli  are  a  greater  menace  than  has  hitherto  been  suspected.  Infants 
may  be  infected  by  mere  contact  with  phthisical  persons.  On  the  other 
hand,  there  is  hardly  a  person  living  in  a  large  city  who  has  escaped 
infection  with  tubercle  bacilli.  In  other  words,  despite  the  vigorous 
and  costly  efforts  which  have  been  made  during  the  past  thirty  years, 
the  majority  of  the  population  in  civilized  countries  harbor  tubercle 
bacilli  in  their  bodies.  But,  what  is  of  more  importance,  not  every 
one  infected  with  tubercle  bacilli  is  destined  to  become  sick.  For  this 
reason,  a  sharp  distinction  is  made  in  the  following  chapters  between 
infection  and  disease,  or  tuberculosis  and  iMhisis. 


VI  PREFACE 

Recent  research  has  also  shown  that  infection  with  tubercle  bacilli 
endows  an  organism  wdth  a  certain  degree  of  resistance,  or  even  im- 
munity, against  further  and  renewed  exogenic  infection  with  the  same 
virus.  Experimental  investigations  of  the  past  ten  years  have  proved 
that  it  is  impossible  to  reinfect  a  tuberculous  animal  with  tubercle 
bacilli.  ]Many  clinical  phenomena,  which  have  hitherto  baffled  those 
who  studied  the  disease,  such  as  the  rarit}''  of  conjugal  phthisis,  or  of 
tuberculous  disease  in  those  living  and  working  among  phthisical 
patients,  are  now  explained  by  this  immunity  of  the  tuberculous  against 
reinfection  with  tubercle  bacilli.  Phthisis  is  at  present  considered 
a  manifestation  of  immunity.  Prophylaxis  of  infection  has  been  shifted 
to  the  child,  while  that  of  phthisis  involves  more  than  prevention  of 
infection. 

In  the  discussion  of  the  clinical  aspects  of  phthisis  an  attempt  has 
been  made  to  elaborate  on  the  constitutional  symptoms,  which  are 
still  the  sheet  anchor  of  the  physician  who  is  charged  with  deciding 
whether  a  patient  is  ill  and  in  need  of  treatment.  Bacteriology  and 
serology  are  excellent  helps  in  showing  whether  the  patient  has  been 
infected  with  tubercle  bacilli;  skiagraphy  reveals  airless  areas  of  lung 
tissue;  but  they  do  not  give  conclusive  proof  that  the  patient  is  sick 
and  in  need  of  prolonged  and  costly  treatment.  We  also  know  that 
unity  of  causation  is  not  always  an  indication  of  unity  of  resulting 
clinical  phenomena  in  tuberculosis :  The  clinical  picture  of  tuberculosis 
in  infants  is  different  from  that  in  children;  in  adults  some,  irrespective 
of  the  treatment  applied,  show  a  marked  tendency  to  sclerosis  or  fibrosis 
of  the  lesion,  in  others  caseation  and  destruction  of  lung  tissue  goes 
on  progressively;  in  still  others  there  is  a  sluggish  course,  marked  by 
periods  of  illness  alternating  with  periods  of  comparative  comfort. 
For  these  reasons  several  tj^pes  of  the  disease,  or  syndromes,  have 
been  described,  each  of  which  has  not  only  a  different  clinical  course, 
but  also  a  different  outlook  as  to  recovery,  and  the  treatment  differs 
markedly  in  each  form  of  the  disease. 

The  treatment  recommended  in  this  book  is  based  on  experience 
with  patients  in  New  York  City.  Some  were  living  in  the  congested 
neighborhoods  of  the  INIetropolis;  others  in  the  better  parts  of  the  city; 
still  others  have  been  under  the  author's  care  in  the  hospital.  A  large 
proportion  had  been  in  sanatoriiuus,  but  even  they  had  to  be  cared 
for  in  their  homes  before  admission  and  after  discharge.  Emphasis 
is  laid  on  the  fact  that  in  most  cases  we  can  give  the  patient  the  benefit 
of  modern  and  appro\ed  treatment  in  his  home  as  well  as  in  institutions. 


PREFACE  vii 

The  immense  utility  of  sanatorium  treatment  is  emphasized  and  its 
limitations  are  enumerated.  It  is  also  shown  that  institutional  treat- 
ment is  not  the  only  nor  the  best  available  method  of  caring  for  the 
majority  of  patients.  Experience  has  taught  that  we  can  properly 
house  and  feed  a  patient  in  the  city  at  a  much  less  expense  than  in  a 
sanatorium. 

Medicinal  treatment  has  been  alloted  some  space  for  the  reason  that 
it  is,  in  many  cases,  believed  to  possess  more  value  than  it  has  been 
accredited  by  therapeutic  nihilists.  The  most  recent  method  of  treat- 
ment, artificial  pneumothorax,  has  been  given  at  some  detail  because 
of  its  efficacy  in  selected  patients  in  whom  everything  else  has  failed  to 
afford  relief. 

The  author  is  under  great  obligations  to  Dr.  William  H.  Park  for 
reading  and  correcting  the  manuscript  of  the  first  two  chapters  dealing 
with  bacteriology,  a  subject  in  which  he  is  a  master.  Dr.  Frederick 
L.  Hoffman  and  his  assistant  Mr.  Frederick  S.  Cram,  of  Newark,  N.  J., 
have  helped  with  the  compilation  of  statistical  data  from  the  recent 
census  reports  and  an  expression  of  gratitude  is  hardly  commensurate 
with  their  labors  in  my  behalf,  and  the  readiness  with  which  they  have 
responded  to  my  requests  for  data  in  a  subject  which  is  their  own. 
The  radiograms  in  this  book  are  from  plates  made  by  Dr.  Thomas 
Scholtz,  radiographer  to  the  Montefiore  Hospital  in  New  York  City.  Six 
have  been  kindly  loaned  to  me  by  Dr.  Charles  Gottlieb,  radiographer  to 
the  Beth  Israel  Hospital.  Such  excellence  as  may  be  possessed  by  the 
illustrations  in  the  chapter  on  percussion  is  due  to  the  skill  of  the 
well-known  illustrator  Lola. 

M.  F. 

New  York,  1916. 


CONTENTS. 


CHAPTER   I. 

The  Tubercle  Bacilli 17-34 

CHAPTER  II. 
Tuberculous  Infection 35-51 

CHAPTER  III. 

The  Epidemiology  of  Tuberculosis 52-75 

CHAPTER  IV. 

Factors  Predisposing  to  the  Evolution  of  Phthisis      ....       76-102 

CHAPTER  V. 
Phthisiogenesis •      •      •     103-120 

CHAPTER  VI. 

Pathology  and  Morbid  Anatomy 121-142 

CHAPTER  VII. 

Symptomatology  of  Phthisis — History  of  the  Patient        .      .      .     143-149 

CHAPTER  VIII. 

Cough  and  Expectoration 150-165 

CHAPTER  IX. 

Fever  and  Nightsweats       . 166-185 

CHAPTER  X. 
Hemoptysis 186-202 

CHAPTER  XI. 

Symptoms    Caused    by    Disturbances   in   the    Gastro-intestinal 

Tract — The  Skin — The  Joints 203-218 

CHAPTER  XII. 

Symptoms  Referable  to  the  Cardiovascular  and  Renal  Systems     219-230 


X  CONTENTS 

CHAPTER  XIII. 
Nervous  Symptoms  of  Phthisis 231-241 

CHAPTER  XIV. 
Inspection  and  Palpation ,     242-252 

CHAPTER  XV. 

Percussion  of  the  Chest  in  Phthisis 253-274 

CHAPTER  XVI. 

Auscultation  of  the  Chest  in  Phthisis 275-289 

CHAPTER  XVII. 
Skiagraphy  in  the  Diagnosis  of  Phthisis 290-300 

CHAPTER  XVIII. 
The  Clinical  Forms  of  Phthisis 301-307 

CHAPTER  XIX. 

Chronic  Phthisis.     Incipient  Stage 308-330 

CHAPTER  XX. 
Chronic  Phthisis.     Advanced  Stage 331-347 

CHAPTER  XXI. 

Acute  Phthisis 348-354 

CHAPTER  XXII. 

Fibroid  Phthisis 355-364 

CHAPTER  XXIII. 

Abortive  Tuberculosis 3(55-3(58 

CHAPTER  XXIV. 

Pulmonary  Tuberculosis  in  Children 3(59-393 

CHAPTER  XXV. 
Phthisis  in  the  Aged 394-397 

CHAPTER  XXVI. 
Complications  of  Phthisis 398-422 

CHAPTER  XXVII. 

Prognosis  in  Pulmonary  Tuberculosis 423-437 


CONTENTS  XI 

CHAPTER  XXVIII. 
Indications  for  Treatment 438-445 

CHAPTER  XXIX. 
Prophylaxis      . 446-460 

CHAPTER  XXX. 

General  Management  of  the  Case 461-470 

CHAPTER  XXXI. 

The  Rest  Cure 471-479 

CHAPTER  XXXII. 

Open-air  Treatment 480-491 

CHAPTER  XXXIII. 
Climatic  Treatment 492-504 

CHAPTER  XXXIV. 

Institutional  Treatment 505-512 

CHAPTER  XXXV. 
Dietetic  Treatment 513-524 

CHAPTER   XXXVI. 
Medicinal  Treatment 525-537 

CHAPTER  XXXVII. 

Specific  Treatment 538-547 

CHAPTER  XXXVIII. 

Symptomatic  Treatment 548-567 

CHAPTER  XXXIX. 
Operative  Treatment — Artificial  Pneumothorax 568-600 

CHAPTER  XL. 

General  Treatment  of  the  Various  Forms  of  Pulmonary  Tuber- 
culosis       601-612 

CHAPTER  XLI. 

Treatment  of  Complications 613-620 

Index  of  Authors       .      .      .• 621 

Index  of  Subjects 627 


PULMONARY  TUBERCULOSIS. 


CHAPTER  I. 
THE  TUBERCLE  BACILLI. 

That  tuberculosis  is  a  transmissible  disease  had  been  suspected 
by  many  ancient  physicians  and  conclusively  proved  by  Villemin  in 
1865,  but  it  remained  for  Robert  Koch  to  isolate  the  microorganism 
which  is  the  infective  agent.  In  1882  he  published  his  first  com- 
munication describing  the  morphology,  staining  reactions,  cultivation, 
and  the  successful  animal  inoculation  of  pure  cultures  of  the  bacilli 
invariably  found  in  tissues  affected  with  tuberculosis. 

Th^  tubercle  Uacillus  is  a  parasite  in  the  full  sense  of  the  word, 
living  and  thriving  only  in  the  bodies  of  animals  and  man,  and  perish- 
ing outside  of  the  animal  body.  It  has  not  been  decided  to  which 
group  of  microorganisms  it  belongs;  in  fact,  we  do  not  as  yet  have 
a  classification  of  bacteria  which  is  completely  satisfactory  to  all  who 
are  competent  to  judge.  It  may  be  said  to  belong  to  the  group  of 
acid-fast  bacteria,  of  which  there  are  many  varieties  to  be  mentioned 
farther  on,  and  may  be  classified  with  the  trichomycetes,  while  some 
consider  At  intermediary  between  the  true  bacteria  and  the  lower 
fungi,  the  hyphomycetes. 

Morphology. — The  morphological  variations  of  the  tubercle  bacilli 
are  dependent  on  their  type  and  virulence,  whether  human,  bovine, 
or  avian,  and  on  the  media  in  which  they  have  been  cultivated.  In 
film  preparations  made  from  cultures  or  from  sputum  expectorated 
by  tuberculous  patients,  the  tubercle  bacillus  appears  as  a  slender 
rod,  usually  straight,  but  very  often  curved,  about  one-fourth  to  one- 
half  the  diameter  of  a  red  blood  corpuscle,  or  -^^-q  mm.  in  length,  on 
the  average.  These  rods,  mostly  rounded  on  the  two  ends,  are  seen 
in  the  preparations  from  secretions  or  tissues,  singly,  in  pairs,  or  in 
heaps,  occasionally  imbedded  in  the  tissue  cells.  They  are  non-motile 
and  have  no  flagella.  Microscopically,  an  enveloping  or  capsular 
substance  can  often  be  made  out  around  each  bacillus,  especially  in 
those  which  have  been  artificially  cultivated  in  serum  for  several 
generations.  Some  individual  bacilli  are  strikingly  pleomorphic, 
in  thread,  club-shaped  with  thickenings  at  either  or  both  ends,  or  with 
filaments  passing  out  from  the  main  rod  at  right  angles,  and  finally 
2 


IS  THE   TUBERCLE  BACILLI 

in  Y-shaped  branchings.  But  these  are  of  no  practical  significance 
because  they  appear  to  be  simply  degenerated  types  of  the  micro- 
organism, although  some  look  at  them  as  the  reverse,  the  result  of 
active  growth  on  a  good  culture  medium  and  amid  favorable  biological 
surroundings.  In  some  individual  bacilli,  vacuoles  are  seen,  giving 
the  rod  the  appearance  of  a  chain  of  cocci.  The  suggestion  that  they 
represent  spores  appears  to  be  erroneous,  because  they  have  no  stronger 
resistance  than  the  body  of  the  bacillus,  and  succumb  to  heat  and 
chemicals  as  fast  as  the  entire  rod.  The  fact  that  it  is  speedily  killed 
by  sunlight  also  indicates  that  the  tubercle  bacillus  has  no  spores. 

Staining. — ^The  tubercle  bacilli  stain  with  basic  dyes,  but  with 
great  difficulty,  and  once  stained  they  part  with  the  color  with  diffi- 
culty. Their  most  important  characteristic  is  their  acid-fast  property : 
While  other  microorganisms  lose  their  stain  when  treated  with  acids 
or  alcohol,  the  tubercle  bacilli  retain  it.  They  are  also  alkali-fast, 
and  when  stained  by  an  acid  dye,  cannot  be  decolorized  by  an  alkali. 
But  it  must  be  mentioned  that  they  are  not  the  only  known  acid-fast 
bacilli.  This  is  one  of  the  sources  of  error  which  at  times  interfere 
with  the  proper  appreciation  of  acid-fast  microorganisms  discovered 
under  the  microscope. 

Much's  Granules. — ^There  have  also  been  found  tubercle  bacilli 
which  have  lost  their  acid-fast  characters  while  remaining  virulent. 
Hans  Much,^  who  has  studied  these  microorganisms  and  by  whose 
name  they  are  generally  known,  describes  two  forms  of  these  granules : 
(1)  A  rod-shaped  granular  organism;  (2)  isolated  granules,  both  of 
which  cannot  be  stained  by  the  Ziehl  method  but  only  by  the  Gram 
method.  Tiey  are  pathogenic  to  animals  and  man  and  are  usually 
found  in  cases  of  slowly  progressing  chronic  phthisis,  fibroid  phthisis, 
cold  abscess,  etc.  It  is  thus  evident  that  before  concluding  that  a 
given  case  lacks  acid-fast  bacilli,  and  is  therefore  not  tuberculous, 
the  Much  granules  are  to  be  looked  for  by  staining  with  the  Gram- 
Much  method.  According  to  W.  H.  Park,  true  tubercle  bacilli  are 
probably  always  present  together  with  the  granules  in  cases  in  which 
the  latter  forms  are  found. 

In  this  country  Charles  N.  Meader^  has  recently  made  a  careful 
study  of  these  granules.  In  his  opinion  "the  biological  relationship 
of  Much's  forms  of  tubercle  bacilli  is  a  matter  of  considerable  interest. 
They  may  be  considered  as  a  natural  stage  in  the  evolution  of  the 
bacillus,  as  the  result  of  degenerative  changes,  or  may  be  classed  as 
spores  {i.  e.,  as  resisting  forms).  The  accumulated  evidence  tends 
to  show  that  they  are  predominantly  found  in  tissues  of  a  distinctly 
fibroid  character,  in  old  cavities,  in  pus  of  cold  abscesses,  in  old  cul- 
tures, in  the  notably  indolent  lupus  lesions  and  in  sclerosed  lymph 
glands— facts,  which  taken  together,  mark  them  as  forms  assumed 
under  unfavorable  conditions  whether  they  be  the  result  of  sporula- 

1  In  Brauer,  Schroder,  and  Blumeufeld,  Haiidhuch  d.  Tubcrkulosc,  vol.  i,  p.  103. 

2  Amer.  Jour.  Med.  Sci.,  1915,  cl,  858. 


POWERS  OF  RESISTANCE  19 

tion  or  of  degeneration.  The  same  conclusion  is  suggested  by  obser- 
vations that  under  favorable  cultural  conditions  they  are  rapidly 
replaced  by  Ziehl-staining  forms.  Against  their  classification  as 
spores  in  the  commonly  accepted  sense  is  the  fact  that  the  granular 
forms  are  rather  less  resistant  to  the  action  of  antiformin  than  are 
the  Ziehl  forms;  their  resistance  to  other  chemical  agents  has  not 
yet  been  reported  upon.  It  is  of  interest  to  note  here  that  the  granular 
forms  appear  more  frequently  in  the  bovine  than  in  the  human  type 
of  bacillus." 

Cultivation. — The  tubercle  bacilli  are  obligatory  aerobes;  they  re- 
quire free  oxygen  for  maintenance  of  life,  activity,  and  propagation. 
In  artificial  media  the}^  grow  very  slowly,  much  slower  than  most 
bacteria  which  are  not  acid-alcohol-fast;  they  proliferate  very  slowly, 
and  other  saprohytic  microorganisms  which  happen  to  live  with  them 
soon  outnumber  them.  It  is  also  worthy  to  remember  that  it  is  diffi- 
cult to  cultivate  them  directly  from  tuberculous  lesions,  secretions, 
and  excretions  of  patients  known  to  contain  tubercle  bacilli.  But 
once  they  have  been  cultivated  it  is  rather  easy  to  transplant  them 
to  another  culture  of  the  same  medium,  and  growth  is  even  more 
luxuriant  in  the  subsequent  cultures.  Theobald  Smith's  method  of 
cultivation  on  dog  serum  and  Dorset's  egg  medium  are  about  the 
best  and  most  used  in  this  country.  Pure  cultures  are  best  obtained 
from  tubercles  of  animals  inoculated  with  the  bacilli.  But  it  is  often 
possible  to  obtain  pure  cultures  from  closed  tuberculous  cavities,  from 
lesions  of  lupus,  and  even  from  sputum. 

When  cultivated  on  coagulated  dog  serum,  or  bovine  serum,  or  in 
Dorset's  egg  medium,  especially  when  to  the  latter  there  is  added 
glycerin,  growth  appears  usually  at  the  end  of  ten  days  at  37°  C, 
and  within  four  weeks  the  characteristic  growth  may  be  expected. 
On  the -glycerin-egg  medium  the  human  form  of  organism  produces 
an  abundant,  wrinkled  layer  usually  having  a  yellowish,  buff,  or 
pinkish  color.  The  growths  are  seen  as  more  or  less  elevated  colonies 
which  may  coalesce.  On  glycerin-agar  the  growth  is  more  rapid  than 
on  serum,  and  appears  as  a  thick,  white  layer,  becoming  yellowish. 
Tubercle  bacilli  also  flourish  in  glycerin-potato  medium. 

Powers  of  Resistance. — The  tubercle  bacilli  grow  best  at  the 
temperature  of  the  human  body,  37°  to  38°  C,  but  growth  is  not 
abolished  at  29°  to  42°  C.  From  a  practical  standpoint  it  is  important 
to  mention  that  they  are  not  killed  when  exposed  to  moist  heat  of 
50°  C.  for  less  than  twelve  hours,  but  heating  to  55°  C.  for  four  to 
six  hours  does  destroy  them.  They  are  also  killed  when  exposed  to 
moist  heat  of  60°  C.  for  one-half  hour,  and  in  fifteen  minutes  at  70° 
C;  in  five  minutes  at  80°  to  90°  C,  and  in  one  minute  at  95°  C.  With 
sputum,  conditions  are  different:  the  mucus  protects  the  bacilli  and 
it  requires  more  time  to  destroy  them  with  heat.  However,  five 
minutes'  boiling  is  sufficient  to  kill  the  bacilli  under  all  circumstances. 

Another  practical  point  is  that  in  milk,  tubercle  bacilli  resist  the 


20  THE   TUBERCLE  BACILLI 

action  of  heat  with  greater  tenacity  than  in  pure  hqiiid  cultures  or 
even  in  sputum.  From  many  careful  experiments  it  appears  that 
heating  milk  for  thirty  to  forty  minutes  at  a  temperature  of  65  °  to  70° 
C,  or  boiling  for  three  minutes,  destroys  tubercle  bacilli.  Especially 
resistant  are  the  bacilli  when  the  milk  is  heated  in  an  open  vessel  and 
a  pellicle  forms  on  the  top  of  the  fluid.  This  protects  the  bacilli  against 
a  temperature  of  60°  C.  for  an  hour.  William  H.  Park  explains  this 
by  the  fact  that  the  upper  parts  of  the  fluid  are  not  heated  to  the 
same  degree  as  the  lower  and  some  bacilli  may  survive.  At  any  rate 
it  is  important  that  pasteurization  should  be  done  in  closed  vessels. 
In  butter  the  virulence  of  the  bacilli  is  greatly  diminished  and  even 
abolished  when  in  contact  for  a  long  time.  In  fact,  the}'  die  out  within 
a  few  weeks  as  a  rule.  The  reasons  for  this  phenomenon  are  not 
clear.  On  the  other  hand,  Schroeder  and  Cotton  have  found  living 
tubercle  bacilli  retaining  their  virulence  for  one  hundred  and  sixty  days 
in  salted  butter  when  kept  without  ice  in  a  house  cellar;  and  Mohler, 
Washburn,  and  Doane  found  that  they  survived  a  year  in  cheese. 
In  thoroughly  boiled  or  roasted  meat  the  bacilli  are  destroyed;  but 
in  the  rare  portions  they  may  survive.  Sausages,  etc.,  made  of 
uncooked  meat,  may  contain  living  tubercle  bacilli. 

Dry  heat  is  less  potent  in  destroying  tubercle  bacilli;  circulating 
steam  requires  one-half  hour  for  this  purpose;  while  bacilli  in  dried 
sputum  can  withstand  a  temperature  of  100°  C.  for  an  hour.  On 
the  other  hand,  cold  does  not  destroy  their  virulence,  and  freezing 
with  subsequent  thawing  does  not  harm  them  very  much. 

It  is  also  important  to  remember  that  the  fatty  substances  and 
wax  contained  in  the  tubercle  bacilli  protect  them  to  a  certain  extent 
from  the  effects  of  desiccation,  and  from  the  bactericidal  action  of 
the  normal  body  cells,  although  for  gro\\i;h  and  proliferation  they 
require  moisture.  When  dried  and  pulverized  by  being  converted 
into  dust,  as  is  often  the  case  with  tuberculous  sputum  eliminated 
indiscriminately  by  careless  patients,  most  of  the  bacilli  succumb, 
but  some  have  been  found  to  resist  desiccation  at  ordinary  tempera- 
ture for  months. 

In  this  connection  it  must  be  borne  in  mind  that  the  action  of  light 
is  an  important  factor.  It  has  been  ascertained  that  light,  especially 
sunlight,  decomposes  the  fatty  substances  in  the  bacilli  and  thus 
destroys  them  altogether.  When  cultures  are  exposed  to  direct  sun- 
light for  a  couple  of  hours  the  vitality  as  well  as  the  virulence  of  the 
tubercle  bacilli ns  destroyed;  in  s'putum  the  bacilli  are  protected  by 
the  mucus,  and  it  requires  a  longer  time  for  their  destruction.  Some 
maintain  that  their  virulence  is  only  destroyed  with  partial  loss  of 
vitality. 

Under  the  circumstances  sputum  eliminated  in  light  places  is 
sooner  or  later  rendered  harmless,  while  when  expectorated  in  dark 
rooms  the  bacilli  may  retain  their  vitality  and  ^•i^ulence  for  a  year, 
and  even  drying  does  not  harm  them  much. 


VIRULENCE  21 

On  the  whole,  tubercle  bacilli  may  retain  their  vitality  for  a  con- 
siderable time  if  not  in  exceptionally  unfavorable  surroundings.  In 
the  latter  case  their  growth  is  soon  hampered,  and  they  cannot  suc- 
cessfully be  transferred  by  inoculation  to  another  culture  medium; 
but  they  may  retain  their  virulence  much  longer  and  cause  disease 
when  inoculated  into  an  animal.  After  several  months,  hov/ever, 
even  this  wanes,  and  after  six  months  this  property  is  also  lost.  In 
laboratories  it  has  been  found  by  experience  that  it  is  safer  to  reinocu- 
late  cultures  every  four  to  six  weeks.  Exceptionally,  cultures  have 
been  found  alive  and  virulent  after  two  years.  This  is  especially  the 
case  with  potato  and  bouillon  cultures  which  have  been  kept  under 
favorable  conditions  as  to  heat,  moisture,  etc.,  while  in  serum  and 
glycerin  cultures  the  bacilli  do  not  survive  so  long. 

Cornet  found  that  serum  cultures  remain  alive  for  about  six  months, 
while  glycerin-agar  cultures  are  often  partially  or  wholly  dead  in  six 
to  eight  weeks.  There  seems  also  to  be  some  difference  in  this  respect 
between  the  various  types  of  tubercle  bacilli:  Maffucci  states  that 
avian  bacilli  may  remain  alive  for  two  years,  and  Strauss  found  that 
cultures  of  human  tubercle  bacilli  are  only  exceptionally  capable  of 
reproduction  after  five  to  six  months;  after  eight  to  twelve  months 
they  fail  regularly.  Theobald  Smith^  recently  found  that  a  culture 
three  months  old  failed,  as  a  rule,  to  yield  successful  subcultures, 
and  that  tubercle  bacilli  of  both  human  and  bovine  types,  when  kept 
in  fully  developed  cultures  at  40°  to  50°  F.,  may  remain  infectious  to 
guinea-pigs  for  from  seven  to  nineteen  months,  but  the  number  of 
bacilli  surviving  in  such  cultures  is  relatively  small. 

The  tubercle  bacilli  display  great  powers  of  resistance  to  the  action- 
of  the  products  of  other  bacterial  growths,  in  spite  of  the  fact  that  they 
have  no  spores.  They  may  survive  for  months  in  souring  milk,  in  sewage 
and  in.water,  and  in  putrefying  matter  generally,  especially  sputum. 

Virulence. — Long  before  the  discovery  of  the  tubercle  bacillus  it 
was  known  that  certain  diseases  in  animals  were  of  the  same  character 
as  human  tuberculosis,  and  attributed  to  the  same  virus.  Klenke,  in 
1846,  emphasized  the  danger  of  milk  from  tuberculous  cattle  as  an 
infective  agent  to  human  beings,  and  Villemin,  in  1865,  showed  by 
animal  experiment  that  tuberculous  disease  in  man  and  animals  is 
identical  in  character.  With  the  study  of  the  virulence  of  the  tubercle 
bacillus  it  was  found  that  it  is  pathogenic  to  many  species  of  animals. 
In  some  tuberculosis  is  known  to  occur  spontaneously,  while  others 
may  be  infected  artificially.  There  appear  to  be  significant  differences 
in  the  results  of  such  experimental  infections,  depending  on  the  method 
of  inoculation  of  the  virus — injections  into  the  subcutaneous  tissues, 
into  the  peritoneum,  into  the  anterior  chamber  of  the  eye,  intravenously 
by  feeding  animals  with  bacilli,  or  cornpelling  them  to  inhale  the, 
bacilli  with  inspired  air  and  also  according  to  the  origin  of  the  bacilli. 

•  Jour.  Med.  Research,  1913,  xxviii,  91. 


22  THE   TUBERCLE  BACILLI 

Tubercle  bacilli  obtained  from  different  cases  of  human  tuberculosis 
often  show  differences  in  their  virulence  according  to  the  strain. 
But  when  the  bacilli  obtained  from  different  animals  are  compared, 
the  differences  in  their  virulence  are  even  more  striking.  For  this 
reason  there  have  been  described  different  species,  varieties,  or  stains  of 
tuberle  bacilli,  although  some  authors  maintain  that  the  differences 
in  cultural  and  virulence  characteristics  are  acquired  while  the  micro- 
organisms are  sojourning  in  the  host  by  adaptation  to  the  conditions 
favorable  for  their  growth. 

HUMAN,  BOVINE,  AND   AVIAN   BACILLI. 

The  first  careful  study  of  differences  in  morphological,  cultural, 
and  pathogenic  types  of  tubercle  bacilli  was  made  by  Theobald  Smith, ^ 
who,  in  1898,  showed  that  there  are  differences  between  the  bacilli 
isolated  from  human  beings  when  compared  with  those  isolated  from 
cattle.  His  designation  of  the  former  as  "human"  and  the  latter  as 
"bovine"  has  since  been  generally  accepted.  In  1901  Robert  Koch 
also  announced  that  his  studies  led  him  to  the  conviction  that  human 
and  bovine  tuberculosis  are  not  identical;  that  the  bovine  bacilli 
are,  in  fact,  not  pathogenic  to  man,  and  that  no  special  measures  need 
be  taken  to  protect  man  against  the  consumption  of  milk  and  meat 
from  tuberculous  cattle.  Considering  the  commercial  interest  which 
was  centred  around  this  problem,  in  addition  to  the  problem  of 
human  infection,  it  is  clear  why  studies  along  these  lines  have  been 
in  abundance  during  recent  years. 

Still  other  types  of  bacilli  have  been  found.  Rivolta  and  Maffucci 
have  shown  that  there  are  certain  morphological  and  biological  dif- 
ferences between  the  tubercle  bacilli  found  in  birds  and  those  in 
human  beings.  Theobald  Smith  continued  to  investigate  the  prob- 
lem, and  arrived  at  the  conclusion  that  bacilli  from  human  sources 
are  not  clearly  identical  in  every  respect  with  those  obtained  from 
bovine  sources.  Official  bodies  of  the  Imperial  Department  of  Health 
in  Germany,  a  Royal  Commission  in  England,  and  Dr.  William  H. 
Park,  for  the  New  York  City  Department  of  Health,  have  thoroughly 
studied  the  problem,  each  from  a  different  angle.  The  result  is  that 
we  are  at  present  in  a  position  to  state  conclusively  that  there  is  more 
than  one  variety  of  tubercle  bacillus. 

The  conclusions  of  the  British  Royal  Commission  are  to  the  effect 
that  "for  the  purposes  of  description  it  is  advantageous  to  distin- 
guish three  types  of  tubercle  bacilli,  recognizable  by  their  individual 
characters.  These  are  the  human,  the  bovine,  and  the  avian.  The 
human  type,  although  so  named,  is  not  the  only  one  found  in  cases 
of  tuberculosis  in  man.  It  is  the  organism  present  in  the  majority 
of  such  cases,  but  in  some  cases  of  human  disease  the  bacilli  present 

1  Jour,  of  Experimental  Medicine,  1898,  iii,  451. 


HUMAN,   BOVINE,  AND  AVIAN  BACILLI  23 

are  of  the  bovine  type,  and  in  others  the  bacilH  have  special  charac- 
ters distinguishing  them  from  each  of  the  three  principal  types.  In 
natural  cases  of  tuberculosis  in  cattle  the  only  type  of  bacillus  present 
is  the  bovine  type."  William  H.  Park^  concludes  from  his  extensive 
study  of  the  subject  that  "tubercle  bacilli,  as  isolated  from  man,  fall 
into  two  groups.  One  of  these  groups  is  identical  in  all  its  characters 
with  those  found  in  cattle.  That  is,  all  tubercle  bacilli  from  man  and 
cattle  fall  into  two  groups,  which  have  been  designated  the  human 
and  bovine  types." 

Human  Bacilli. — The  human  variety  grows  on  all  culture  media 
quickly  and  luxuriantly;  the  addition  of  glycerin  enhances  their 
growth.  On  glycerin  bouillon  growth  is  seen  during  the  first  few 
days,  and  within  three  weeks  there  is  seen  a  pellicle  on  the  surface  of 
the  culture  which  spreads  laterally  and  reaches  the  glass  walls.  The 
pellicle  is  fragile  and  its  surface  wrinkled.  Morphologically,  the 
human  bacilli  when  grown  on  serum  cultures  appear  as  long,  straight, 
or  curved  rods  which  are  unevenly  stained. 

In  general  it  may  be  stated  that  the  virulence  of  human  bacilli  is 
rather  low  in  various  animals.  Guinea-pigs  are  very  susceptible  and 
may  be  infected  in  various  ways,  even  by  rubbing  the  bacilli  into  the 
shaved  skin  of  the  abdomen.  Rabbits  are,  however,  less  susceptible. 
Even  when  a  milligram  of  bacilli  is  injected  into  a  vein  of  the  ear  there 
is  only  produced  a  chronic  lesion  which  may  heal;  subcutaneous 
injection  produces  an  infiltration  at  the  point  inoculated  which  soon 
softens  and  empties  itself  through  a  fistulous  opening,  or  may  even 
be  absorbed.  The  regional  lymph  glands  swell,  but  do  not  caseate. 
At  times,  but  not  in  every  case,  there  may  thus  be  produced  a  chronic 
infection  of  the  lungs  in  the  rabbit.  Intraperitoneal  inoculation 
produces  tuberculous  peritonitis,  which  may  extend  along  the  dia- 
phragm;, infection  of  the  anterior  chamber  of  the  eye  produces  a  lesion 
which  develops  more  slow  than  when  bovine  bacilli  are  used.  Cattle 
are  infected  when  large  doses  are  injected  intravenously.  But  with 
subcutaneous  infection  there  is  produced  only  an  infiltration  at  the 
point  inoculated  which  soon  suppurates  and  heals.  The  regional 
lymph  glands  swell  up  and  at  times  become  calcified.  Feeding 
calves  with  human  bacilli  never  produces  any  progressive  disease. 
Pigs,  dogs,  cats,  and  sheep  are  not  at  all  affected  by  human  bacilli, 
while  monkeys  are  very  susceptible.  Some  species  of  birds  are  also 
susceptible. 

Bovine  Bacilli. — The  bovine  bacilli  are  very  difficult  to  cultivate; 
it  appears  that  the  addition  of  glycerin  to  the  culture  medium  slackens 
their  growth.  On  glycerin  bouillon  growth  is  very  slow.  A  thin 
pellicle  is  formed  which  spreads  all  over  the  surface  within  four  to 
eight  weeks,  but  it  may  remain  limited  to  the  centre  of  the  surface. 
Onh'  rarely  are  a  few  verrucose  thickenings  formed  on  the  surface. 

1  Jour.  Med.  Research,  1911,  xx,  313     1912,  xxii,  109, 


24  THE   TUBERCLE  BACILLI 

After  several  transplantations  they  may  show  greater  tendencies  to 
grow.  Morphologically,  they  appear  as  shorter,  thicker,  and  more 
evenly  stained  than  the  human  variety,  and  usually  bent,  showing  bead- 
ing and  irregularities  in  staining.  Park,  wdio  has  done  excellent  work 
along  these  lines,  says:  "Although  one  could  in  many  instances 
make  a  probable  diagnosis  of  type  from  an  inspection  of  the  smear, 
the  number  of  intermediate  gradations  in  morphological  differences 
rob  it  of  nearly  all  its  practical  value." 

The  bovine  bacilli  are  more  virulent  for  rabbits,  calves  and  swine 
than  the  human.  Guinea-pigs  are  just  as  susceptible  to  them  as 
they  are  to  the  human  variety,  but  in  addition  they  are  killed,  or 
become  acutely  and  progressively  sick  when  infected  with  small 
doses  of  bovine  bacilli.  The  difference  in  the  virulence  of  the  two 
types,  is  well  seen  in  the  rabbit.  The  bovine  type  of  virus  causes  in 
every  instance  a  generalized  miliary  tuberculosis,  progressive,  and 
causing  the  death  of  the  animal.  "Human  virus  injected  in  the 
same  amount  produces  either  no  disease  at  all,  or  lesions  of  varying 
severity  in  the  lungs  or  kidneys  or  both,  and  never  causes  generalized 
miliary  tuberculosis.  Even  with  1  mg.,  that  is  one  hundred  times 
as  much,  the  lesions  are  usually  confined  to  the  same  organs,  and 
though  there  is  a  very  slight  tendency  to  generalization  with  this 
dose,  there  is  never  a  generalization  showing  a  progressive  nature. 
Rabbits  injected  even  with  the  larger  dose  live  indefinitely,  and,  if 
death  should  occur  the  tuberculous  lesions  are  usually  not  extensive 
enough  to  say  that  the  animal  died  of  the  disease."  (Park  and 
Krumwiede.) 

Cattle  are  also  very  susceptible  to  the  bovine  virus,  and  after 
intravenous  injection  perish  from  generalized  tuberculosis  within 
three  or  four  weeks.  Intraperitoneal,  intra-ocular,  and  intramam- 
mary  inoculation  also  cause  generalized  and  fatal  tuberculosis. 
Feeding  cattle  with  even  small  doses  of  pure  culture  of  bovine  tubercle 
bacilli  causes  tuberculous  disease  of  the  intestines,  followed  by  tuber- 
culous lymphangitis  and  lymphadenitis  of  the  mesentery;  the  disease 
spreads  to  other  lymph  glands,  serous  membranes,  and  lungs.  Inhala- 
tion produces  caseous  pneumonia.  After  subcutaneous  injections 
there  is  produced  an  infiltration  at  the  point  inoculated,  swelling  of 
the  regional  lymph  glands  and  generalized  tuberculosis,  the  animal 
perishing  within  two  or  three  months.  Pigs,  sheep,  goats,  cats,  and 
monkeys  are  very  susceptible;  dogs,  rats,  and  mice  are  more  or  less 
refractory.  Some  species  of  birds  are  susceptible,  but  chickens  show 
complete  resistance. 

Avian  Bacilli. — On  glycerin  agar  and  on  serum  their  growth  is  more 
luxuriant,  appears  more  moist  or  slimy  than  observed  among  mam- 
malian bacilli,  and  they  produce  an  orange  pigment.  They  grow  at 
the  temperature  of  41°  C.  which  stops  the  growth  of  mammalian 
tubercle  bacilli.  Morphologically,  the  differences  are  insignificant. 
The  Royal  Commission  found  that  rabbits,  rats,  and  mice  are  the 


PLATE  I 


Tubercle    bacilli    in    red. 
Streptobacilli  in  blue. 


Turbercle    bacilli    in    red. 
Tissue  in  blue. 


X  lOOO  diameters. 


X  nOO  diameters. 


FIG.   3 


Leprosy  bacilli  in  nasal  seere-       Short  smegma   bacilli  in  red, 
tion  of  person  suffering  from  rest  of  nnaterial  in  blue. 

nasal  lesions.     (Hansen.) 


X  SCO  diameters. 


X  HOC  diameters. 


(From  Park's  Pathogenic  Microorganisms, 


HUMAN,   BOVINE,  AND  AVIAN  BACILLI  25 

only  mammals  susceptible  to  inoculation  with  avian  tubercle  bacilli. 
Fowls  are  very  susceptible  when  fed  with  portions  of  the  organs 
containmg  avian  bacilli,  but  they  may  consume  enormous  quantities 
of  phthisical  sputum  without  becoming  tuberculous.  On  the  other 
hand,  the  parrot  is  susceptible  to  both  human  and  bovine  bacilli  as 
well  as  to  avian,  and  spontaneous  tuberculosis  may  be  due  to  any  of 
the  types.  Tuberculosis  is  very  common  among  domesticated  birds 
and  there  have  been  observed  veritable  epidemics  of  the  disease  in 
poultry  yards. 

Tubercle  Bacilli  of  Cold-blooded  Animals. — Certain  diseases  ob- 
served in  worms,  lizards,  frogs,  turtles,  snakes,  and  fish  have  great 
resemblance  to  human  tuberculosis  and  in  many  cases  acid-fast  bacilli 
have  been  isolated.  These  microorganisms  grow  luxuriantly  in  the 
room  temperature,  the  growth  being  thick  and  moist  like  that  of 
avian  bacilli,  and  a  higher  temperature  than  30°  C.  inhibits  their 
growth.  While  they  do  not  grow  at  the  body  temperature,  it  appears 
that  some  have  been  able  to  acclimatize  them  to  a  temperature  of  36°. 
C.  Weber  and  Taute  have  cultivated  this  microorganism  from  mud 
and  also  from  healthy  frogs.  They  therefore  conclude  that  these 
acid-fast  bacilli  have  nothing  in  common  with  tubercle  bacilli,  but 
they  are  saprophytes  which  may  be  found  in  healthy  animals  and  in 
the  soil.  Others,  however,  consider  them  as  true  pathogenic  bacilli 
of  cold-blooded  animals,  or  such  as  have  become  attenuated  in  their 
virulence  by  a  long  residence  in,  and  adaptation  to  growth  in,  a  lower 
temperature. 

Attempts  have  been  made  to  use  these  bacilli  for  the  purpose  of 
immunization  against  infection  with  mammalian  tubercle  bacilli, 
but  they  were  unsuccessful.  F.  F.  Friedmann  has  even  claimed 
that  bacilli  obtained  from  turtles  are  curative  of  existing  tuberculous 
disease,'  but  the  results  obtained  have  not  justified  in  the  slightest 
his  pretensions. 

Other  Acid-fast  Bacilli. — The  tubercle  bacilli  are  not  the  only 
variety  of  microorganisms  which,  once  stained,  refuse  to  be  decolorized 
by  acids  and  alcohol.  There  have  been  found  many  others  presenting 
the  same  staining  reactions  as  the  tubercle  bacilli  and  there  is  no 
doubt  that  they  may  bring  about  confusion  in  diagnosis.  Of  these 
we  may  mention  the  following: 

The  smegma  bacillus  is  a  slender,  slightly  curved  rod,  not  unlike 
the  tubercle  bacillus  but  distinctly  shorter,  and  resists  the  action  of 
acids  after  staining.  It  is  found  in  the  secretions  of  the  external 
genitals,  mammae,  etc.,  especially  when  these  secretions  contain  fatty 
matter,  and  there  have  been  reported  cases  in  which  extirpation  of 
kidneys  were  made  mistaking  these  microorganisms  for  tubercle  bacilli. 

The  Bacillus  leprae  also  has  great  similarity  to  the  tubercle  bacillus. 
(See  Plate  I.) 

Moeller's  grass  bacilli  are  found  in  infusions  of  timothy-grass 
('phJeum  praiense),  resemble  morphologically  the  tubercle  bacilli,  and 


26  .  THE   TUBERCLE  BACILLI 

are  acid-fast.  Inoculations  produce  lesions  exquisitely  resembling 
tubercles. 

]Moeller  has  also  described  a  bacillus  found  in  milk,  e\'en  in  pasteur- 
ized milk,  according  to  Kuthy.  Its  similarity  to  the  tubercle  bacillus 
is  even  more  pronounced  than  most  of  the  other  pseudotubercle 
bacilli.  Inoculated  into  the  peritoneal  cavity  of  guinea-pigs,  white 
mice,  and  frogs,  these  pseudotubercle  bacilli  obtained  from  tonsils, 
tongue  and  throat  produced  lesions  which  had  great  similarity,  micro- 
scopically, to  real  tubercles,  but  they  never  spread  beyond  these 
areas.  The  only  difference  which  can  be  discovered  is  that  while 
tubercles  are  of  a  proliferative  character,  these  pseudotubercles  are 
of  a  more  exudative  and  inflammatory  character,  showing  a  tendency 
to  abscess  formation. 

Doerr  and  others  have  also  isolated  acid-fast  rods  from  the  excre- 
ments of  cattle,  swine,  sheep,  guinea-pigs,  white  mice,  chickens,  dogs, 
etc.  In  fact  they  are  so  frequent  in  the  soil  that  any  being  or  thing 
coming  in  contact  with  the  soil  is  likely  to  have  acid-alcohol-fast  rods 
when  carefully  examined  with  the  microscope.  Doerr  also  found  them 
in  the  dust  in  ordinary  houses,  in  tap  water,  in  centrifuge  tubes,  in 
the  sediment  of  a  laboratory  flask,  also  in  a  flask  of  distilled  water; 
finally  in  cerumal  tartar  on  the  teeth,  and  in  the  cerumen  of  the 
human  ear  and  also  in  the  mouth-pieces  of  musical  instruments.  He 
found  two  forms  which  usually  occur  together:  One  a  short,  thick 
rod,  and  the  other  a  long  and  thin  rod,  very  much  like  the  tubercle 
bacillus.    ]\Iuch's  stain  shows  usually  a  granular  structure  of  the  rod. 

Similarly,  there  have  been  isolated  microorganisms  from  cow's 
milk,  butter,  and  from  the  surface  of  domestic  animals,  which  mor- 
phologically, culturally,  and  even  on  inoculation  resemble  tubercle 
bacilli.  The  butter  bacillus,  first  described  by  Petri  and  Rabinowitsch, 
may  be  mistaken  for  the  tubercle  bacillus  even  when  inoculated  into 
guinea-pigs.  D.  J.  Davis^  recently  described  an  acid-fast  streptothrix 
producing  certain  infection  in  the  pulmonary  tissues  which  may  be 
mistaken  for  tuberculosis.  ^Microscopically,  there  may  be  difficulty 
in  distinguishing  them,  but  negative  results  with  guinea-pigs  clear  up 
the  case. 

It  seems  that  the  cellular  structure  of  these  pseudotubercle  bacilli 
is  closely  related  to  that  of  the  pathogenic  tubercle  bacilli,  at  any 
rate  chemically,  as  is  clearly  shown  by  their  similarity  in  staining 
reactions,  and  their  effects  locally  when  inoculated  into  animals. 
Some  produce  lesions  not  unlike  those  produced  by  the  virulent 
tubercle  bacilli,  excepting  that  the  general  toxemia  is  lacking  and 
the  lesion  never  spreads  beyond  the  point  of  inoculation.  It  has  also 
been  found  that  animals  sensitized  to  any  type  of  the  non-virulent 
acid-fast  bacilli,  are  also  to  some  degree  sensitized  to  the  virulent  form. 
But  whether  they  are  phylogenetically  related,  i.  e.,  whether  they 
all  have  evolved  from  a  common  ancestry  has  not  been  established. 

1  Jour.  Infect.  Diseases,  1914,  xiv,  144. 


THE   VARIOUS   TYPES  OF   TUBERCLE  BACILLI  27 

That  they  have  not  differentiated  because  of  the  variety  of  environ- 
ment in  which  they  have  lived  for  many  generations  is  proved  by  the 
fact  that  all  efforts  at  making  them  pathogenic  by  passage  through 
the  bodies  of  various  animals  for  several  generations  have  failed. 
They  always  remain  benign  in  their  effect  on  the  animal  organism. 
The  only  biological  characteristic  they  have  in  common  with  virulent 
tubercle  bacilli  are:  Their  acid-fast  properties,  and  their  aptitude 
for  causing  local  reactions  when  inoculated  into  animals.  The  tubercle 
bacilli  are  alone  able  to  produce  general  reactions.  According  to 
Kendal,  Day,  and  Walker^  the  metabolism  of  the  smegma  and  grass 
bacilli  resembles  that  of  the  rapidly  growing  human  bacilli.  The 
lepra  bacillus  does  not  present  this  metabolic  phenomenon. 

It  has  been  asked  whether  these  acid-fast  bacilli  may  not  interfere 
with  the  diagnostic  significance  of  the  tubercle  bacilli.  Muir  and 
Ritchie^  thus  summarize  this  problem:  "The  source  of  any  acid-fast 
bacilli  in  question  is  manifestly  of  importance,  and  it  may  be  stated 
that  when  these  have  been,  obtained  from  some  source  outside  the 
body,  or  when  contamination  from  without  has  been  possible,  their 
recognition  as  tubercle  bacilli  cannot  be  substantiated  by  microscopic 
examination  alone.  In  the  case  of  material  coming  from  the  interior 
of  the  body,  however — sputum,  etc. — the  condition  must  be  looked 
on  as  different,  and  although  an  acid-fast  bacillus  (not  tubercle)  has 
been  found  by  Lydia  Rabinowitsch  in  a  case  of  pulmonary  gangrene, 
we  have  no  sufficient  data  for  saying  that  acid-fast  bacilli  other  than 
the  tubercle  bacillus  flourish  within  the  tissues  of  the  human  body, 
except  in  such  rare  instances  as  to  be  practically  negligible  (to  this 
statement  the  case  of  the  leprosy  in  bacillus  is,  of  course,  an  excep- 
tion). Accordingly,  up  until  now  the  microscopic  examination  of 
sputum,  etc.,  cannot  be  said  to  have  had  its  validity  shaken,  and  we 
have  the -results  of  enormous  clinical  experience  that  such  examina- 
tion is  of  practically  unvarying  value.  Nevertheless,  the  facts  estab- 
lished with  regard  to  other  acid -fast  bacilli  must  be  kept  carefully  in 
view,  and  great  care  must  be  exercised  when  only  one  or  two  bacilli 
are  found,  especially  if  they  deviate  in  their  morphological  characters 
from  the  tubercle  bacillus.  In  such  cases  inoculation  may  be  the  only 
reliable  test." 

OCCURRENCE    OF   THE   VARIOUS    TYPES    OF   TUBERCLE 

BACILLI. 

The  Human  Type.— The  human  type  is  found  in  the  vast  majority 
of  cases  of  all  forms  of  tuberculosis  in  human  beings;  in  adults  phthisis 
is  almost  exclusively  caused  by  this  virus.  In  spontaneous  tuberculosis 
in  hogs  a  small  percentage  also  shows  this  type  of  bacilli,  and  many 
species  of  animals,  especially  those  coming  in  contact  with  man 
also  are  occasionally  infected  with  human  tubercle  bacilli.     This  is 

1  Jour.  Infeot.  Dis.,  1914,  xv,  431. 

2  Manual  of  Bacteriology,  New  York,  1913,  p.  292. 


28  THE   TUBERCLE  BACILLI 

the  case  with  parrots  and  some  animals  in  zoological  gardens 
in  cities,  like  lions,  antelopes,  gnu,  chimpanzees,  macacus  rhoesiis, 
etc.,  that  have  been  found  infected  with  the  human  bacilli.  The  dog, 
rat,  and  mouse  are  practically  .immune,  while  the  calf,  rabbit,  hog, 
and  goat  occupy  intermediate  positions. 

The  bovine  type  of  tubercle  bacilli  is  responsible  for  disease  in 
domestic  animals  as  cattle,  sheep,  goats,  horses,  etc.  In  most  cases 
of  tuberculosis  in  pigs,  cats,  and  dogs,  and  in  many  cases  in  mon- 
keys, the  bovine  bacilli  are  found. 

The  avian  type  is  found  in  the  vast  majority  of  tuberculous  infec- 
tions in  birds.  Not  only  are  fowls  affected  but  also  birds  in  zoological 
gardens  are  susceptible  and  are  often  sick  as  the  result  of  infection 
with  this  virus.  Spontaneous  tuberculosis  in  horses,  swine,  monkeys, 
cattle,  mice,  and  rats  has  been  found  at  times  to  be  due  to  this  type 
of  bacillus. 

Bovine  Type  of  Bacillus  Tuberculosis  in  Man. — Of  greater  impor- 
tance is  the  occurrence  of  bovine  and  avian  infection  in  human  beings. 
After  Koch  stated  that  the  bovine  bacilli  were  not  at  all  identical  with 
the  human,  and  that  they  were  not  at  all  pathogenic  in  man,  various 
investigations  have  been  m^de  with  the  result  that  Koch  was,  on  the 
whole,  not  sustained.  There  is  evidence  to  the  effect  that  many 
cases  of  tuberculosis  in  human  beings,  especially  in  children,  are  due 
to  the  bovine  virus.  A  large  collection  of  rep>orted  cases  was  pub- 
lished by  Park  and  Krumwiede,  embracing  940  instances  of  tuber- 
culosis carefully  studied  as  to  the  type  of  organism  present,  and  it 
appears  that  in  adults,  sixteen  years  of  age  and  over,  only  tuberculosis 
of  the  skin,  abdominal  organs  and  general  tuberculosis  of  alimentary 
origin  may,  at  times,  be  caused  by  bovine  bacilli.  It  is,  however,  a 
fact  that  but  comparatively  few  cases  have  been  investigated,  and 
there  is  a  lurking  suspicion  that  in  a  larger  series  of  cases  the  propor- 
tion would  be  much  smaller.  On  the  other  hand,  among  778  cases 
of  pulmpnary  tuberculosis  only  3,  or  0.4  per  cent,  were  found  with 
bovine  bacilli,  showing  conclusively  that  as  regards  phthisis,  the  bovine 
type  of  bacilli  is  not  to  be  considered  a  factor  in  the  pathogenesis  of 
the  disease. 

Percentage  of  Incidence  op  Bovine  Tuberculosis  in  940  Cases  of  which 
778  were  Pulmonary  Tuberculosis  (Park  and  Krumwiede). 

Adults  16  years     Children  5     Children  un- 
and  over.  to  16  years,      der  5  years. 

Diagnosis.  Per  cent.  Per  cent.         Per  cent. 

Pulmonary  tuberculosis 0.4  0.0  2.8 

Tuberculous  adenitis,  cervical 2.7  38.0  61.0 

Abdominal  tuberculosis 20 . 0  53 . 0  58.0 

Generalized  tuberculosis,  alimentary  origin        .      .  14.0  57.0  47.0 

Generalized  tuberculosis 0.0  16.0  8.6 

Generalized  tuberculosis  including  meninges,    ali- 
mentary origin 0.0  0.0  66. 0 

Tubercular  meningitis  (with  or  without  generalized 

lesions  other  than  preceding) 0.0  0.0  4.6 

Tuberculosis  of  bones  and  joints 3.3  6.S  0.0 

Tuberculosis  of  skin 23.0  60.0  0.0 


POISONS  PRODUCED  BY   THE   TUBERCLE  BACILLI  29 

In  children  the  picture  is  different.  Under  five  years  of  age  61  per 
cent,  of  the  cervical  tuberculous  adenitis,  58  per  cent,  of  the  abdominal 
tuberculosis  and  66  per  cent,  of  the  generalized  tuberculosis  and  men- 
inges, of  alimentary  origin,  are  caused  by  the  bovine  virus.  Park's 
conclusions  are  as  follows: 

"Bovine  tuberculosis  is  practically  a  negligible  factor  in  adults. 
It  very  rarely  causes  pulmonary  tuberculosis,  which  causes  the  vast 
majority  of  tuberculosis  in  man,  and  is  the  type  of  disease  responsible 
for  the  spread  of  the  virus  from  man  to  man. 

"In  children,  however,  the  bovine  type  of  tubercle  bacillus  causes 
a  marked  percentage  of  cases  of  cervical  adenitis  leading  to  operation, 
temporary  disablement,  discomfort,  and  disfigurement.  It  causes  a 
large  percentage  of  the  rarer  types  of  alimentary  tuberculosis  requir- 
ing operative  interference,  or  causing  the  death  of  the  child  directly 
or  as  a  contributing  cause  in  other  diseases. 

"In  young  children  it  becomes  a  menace  to  life  and  causes  from 
6|  to  10  per  cent,  of  the  total  fatalities  from  this  disease." 

Theobald  Smith^  concludes  that  infection  with  bovine  bacilli  in 
man  occurs  almost  exclusively  through  the  digestive  tract  as  the 
portal  of  entry.  "  It  has  been  found  in  the  tonsils,  the  cervical  lymph 
nodes,  and  in  other  organs  in  the  generalized  disease  starting  from 
these  primary  foci.  It  is  probable  that  De  Jong  and  Arloing  isolated 
it  from  sputum.  (Others  have  done  it  since.)  But  the  fact  remains 
that  bovine  infections  are  essentially  alimentary  in  origin  and  localiza- 
tion, and  largely  restricted  to  childhood.  A  rough  and  liberal  estimate 
would  make  from  one-fourth  to  half  the  cases  starting  in  the  cervical 
and  mesenteric  lymph  nodes  bovine  in  origin." 

POISONS   PRODUCED   BY   THE   TUBERCLE   BACILLI. 

When  tubercle  bacilli  enter  the  human  body  they  do  harm  in 
various  ways.  Locally,  they  destroy  the  tissues  on  which  they  have 
settled,  producing  coagulation  necrosis,  etc.,  which  will  be  discussed 
later  on.  By  their  proliferation  they  also  produce  general  disturb- 
ances in  the  functions  of  the  invaded  body  which  can  only  be  explained 
as  caused  by  some  poison  liberated  by  the  bacilli.  The  nature  of  these 
poisons  is  obscure  at  present,  although  strong  efforts  have  been  made 
to  ascertain  all  the  facts  in  this  respect. 

When  dead  tubercle  bacilli  are  injected  subcutaneously  into  the 
healthy  animal,  a  distinct  inflammation  is  produced  at  the  site  of  the 
inoculation,  frequently  followed  by  suppuration.  It  is  immaterial 
whether  the  bacteria  have  been  killed  by  chemicals  or  by  heat,  the 
result  is  the  same  in  either  case.  When  dead  tubercle  bacilli  are 
injected  intravenously  into  rabbits,  provided  a  sufficient  quantity 
is  employed  for  the  purpose,  a  proliferation  of  tissue  in  the  lung  is 

*  Sixth  International  Congress  on  Tuberculosis,  1908,  iv,  651. 


30  THE   TUBERCLE  BACILLI 

produced  similar  to  that  of  tubercles,  containing,  as  it  does,  giant 
cells  which  may  caseate.  After  intratracheal  injections,  tuberculous 
nodules  with  epithelioid  and  giant  cells  are  produced. 

On  the  other  hand,  when  fluids  containing  the  products  of  the  metab- 
olism of  tubercle  bacilli  are  injected  in  very  large  doses  into  normal 
and  healthy  animals,  no  toxic  effects  are  produced. 

These  and  other  facts  tend  to  show  that  the  effects  of  the  bacilli 
on  the  animal  body  are  not  due  to  mechanical  irritation  produced 
at  the  site  of  the  inoculation,  but  are  the  result  of  the  liberation  of 
toxic  matter  which  acts  both  locally,  producing  coagulation  necrosis, 
and  generally  producing  fever,  etc.  We  know  this,  but  all  attempts 
to  isolate  a  true  toxin  from  tubercle  bacilli  have  utterly  failed,  and 
with  the  intensive  studies  that  have  been  made  during  the  past  thirty 
years  along  these  lines,  we  have  not  yet  been  able  to  clearly  define 
the  tuberculous  poisons.  They  appear  to  be  part  and  parcel  of  the 
living  protoplasm  of  the  tubercle  bacilli  and  liberated  only  after 
the  latter  have  been  destroyed.  In  other  words,  the  tubercle  bacilli 
belong  to  a  group  of  microorganisms  which  do  not  secrete  soluble 
toxins,  but  nevertheless  produce  general  effects  on  the  body  which 
they  invade;  their  deleterious  effects  are  the  result  of  the  action  of 
endotoxins. 

Tuberculin. — Koch  was  the  first  to  discover  that  when  dead  tubercle 
bacilli  are  injected  in  large  quantities  into  tubercid(Ais  animals,  death 
is  caused;  when  small  doses  are  injected,  only  a  slight  reaction  is 
caused  at  the  site  of  the  inoculation  which  soon  heals.  On  repeated 
inoculations  he  observed  improvement  in  the  condition  of  the  sick 
animal.  On  these  experimental  findings  he  based  his  suggestion  for 
the  use  of  tuberculin  as  a  diagnostic  and  therapeutic  agent  in  tuber- 
culosis. 

Tuberculin  consists  mainly  of  the  culture  fluid  in  which  the  bacilli 
have  grown,  of  disintegrated  bacilli  or  extracts  of  their  protoplasm, 
or  both.  As  originally  prepared  by  Koch,  the  following  process  is 
pursued : 

Tubercle  bacilli  are  cultivated  on  bouillon  made  from  fresh  \eal 
to  which  1  per  cent,  of  dried  peptone,  0.5  per  cent,  of  sodium  chloride, 
and  5  per  cent,  of  glycerin  are  added.  Within  six  to  eight  weeks  of 
luxuriant  growth  at  38°  C.  the  culture  is  poured  into  an  evaporating 
dish,  placed  on  a  water  bath  and  evaporated  to  one-tenth  the  original 
volume,  and  any  remains  of  bacilli  are  removed  by  filtration.  Con- 
taining 50  per  cent,  of  glycerin,  the  resulting  preparation  is  quite  stable. 

It  is  thus  clear  that  tuberculin  is  not  a  true  toxin,  nor  is  it  a  pure 
endotoxin;  but  a  50  per  cent,  glycerin  solution  of  the  products  of 
macerated  tubercle  bacilli  in  the  cultiu-e  Huid  which  are  not  destroyed 
l)y  heat,  and  also  any  portion  of  bacilli  which  remains  in  the  solution, 
or  both. 

Ever  since  the  introduction  of  this  original  tuberculin,  many 
other  methods  of  preparation  have  been  devised  by  Koch  himself 


POISONS  PRODUCED  BY   THE   TUBERCLE  BACILLI  31 

and  others,  but  all  have  shown  that  the  active  principle  is  practically 
the  same. 

The  Action  of  Tuberculin. — There  are  differences  of  opinion  as  to 
whether  tuberculin  depends  in  its  action  on  a  certain  chemjcal  prin- 
ciple, or  on  several  chemical  substances.  In  fact  the  chemical  com- 
position of  this  preparation  is  obscure.  Some  have  suggested  that  the 
active  principle  is  a  proteid  or  albumose.  Klebs,  Levene,  and  others 
believe  that  they  have  isolated  various  active  principles;  some  have 
even  obtained  typical  tuberculin  reactions  with  these  substances. 
But,  as  will  be  shown  when  discussing  the  tuberculin  reaction,  any 
protein  inoculated  into  a  tuberculous  individual  produces  the  same 
effects — tuberculosis  being  invariably  accompanied  by  an  altered 
reactivity  to  these  substances.  It  can  be  said  emphatically  that  at 
the  present  state  of  our  knowledge  we  are  in  the  dark  as  to  the  active 
principle  of  tuberculin. 

Healthy  animals  bear  the  injection  of  tuberculin  in  large  doses 
without  any  harm;  the  same  is  true  of  healthy  human  beings.  Koch 
injected  into  his  own  body  0.25  c.c.  of  tuberculin  and  suffered  from  a 
severe  reaction;  after  his  death  an  autopsy  showed  that  he  had  suf- 
fered from  extensive  pulmonary  tuberculosis.  On  the  other  hand. 
Hamburger  administered  as  much  as  500  mgs.  of  tuberculin  into 
non-tuberculous  infants  and  children  without  producing  the  slightest 
local  or  general  reaction.  Clinical  experience  among  human  beings, 
as  well  as  in  cattle — in  which  it  is  easy  and  feasible  to  determine  by 
autopsy  whether  there  are  tuberculous  lesions — ^has  shown  that  a^ 
reaction_a£tfir_a  large  dose- xlL  tuberculin  in  an  apparently  healthy 
person  is  conclusive  proof  of  an  existing  tuberculous  lesion  some- 
where in  the  body.  We  shall  show  later  on  that  this  is  true  of  the 
vast  majority  of  people  in  civilized  communities,  and  therefore  reac- 
tions to  large  doses  of  tuberculin  are  of  very  little  value  to  the  clinician 
who  looks  for  active  tuberculosis. 

The  reason  why  tuberculin  is  harmless  in  healthy  organisms  and 
produces  such  a  pronounced  reaction  when  injected  into  tuberculous 
organisms  are  not  clear.  Various  theories  have  been  advanced  to 
explain  it.  The  most  widely  accepted  explanation  is  that  of  Wolft*- 
Eisner.  He  assumes  that  tuberculous  infection  produces  specific 
antibodies  in  the  tissues  which  break  down  the  tuberculin  molecule, 
just  as  the  digestive  enzymes  break  down  certain  albumin  molecules 
producing  innocuous  and  highly  poisonous  albumoses.  The  antibody 
which  acts  in  this  manner  he  calls  tuberculolysin.  In  non-tuberculous 
organisms  there  is  no  tuberculolysin,  and  when  tuberculin  is  injected 
it  circulates  within  the  juices,  producing  no  toxic  effects,  and  is  finally 
eliminated,  like  other  harmless  foreign  proteins.  In  the  tul)erciilous 
organism  the  tuberculin  comes  in  contact  with  the  lysin,  breaks  it 
up,  and  liberates  a  toxic  substance  which  produces  the  reaction. 

Phenomena  of  Hypersensitiveness. — When  a  rabbit  is  infected  with 
tubercle  bacilli,  and  four  weeks  later  0.1  to  0.3  c.c.  of  tuberculin  is 


32  THE   TUBERCLE  BACILLI 

injected  subcutaneously,  the  animal  succumbs  within  six  to  twenty- 
four  hours.  Koch  found  that  in  animals  infected  eight  to  ten  weeks 
previously,  0.01  c.c.  of  tuberculin  is  sufficient  to  cause  death.  Injec- 
tions of  very  small  doses  into  tuberculous  animals  produce  only  a 
more  or  less  severe  reaction — fever,  loss  of  weight,  etc.  This  is 
obtained  with  injections  of  either  living  or  dead  tubercle  bacilli. 

When  repeated  small  doses  of  tuberculin  are  injected,  certain 
phenomena  are  observed  which  are  not  unlike  those  obtained  after 
the  injection  of  other  foreign  protein  substances  into  an  animal. 
The  tuberculin  reaction  is  evidently  a  manifestation  of  tuberculo- 
protein  hypersensitiveness.  Some  authors  have,  indeed,  been  inclined 
to  ascribe  the  reaction  to  tuberculin  to  the  action  of  the  non-specific 
substances,  glycerin,  proteins,  extractives,  etc.,  contained  in  the 
tuberculin  and  have  argued  that  the  reactions  to  repeated  inoculations 
are  anaphylactic  phenomena.  Perhaps  the  fact  that  the  usual  dose 
of  tuberculin  does  not  contain  enough  of  foreign  proteins,  disproves 
this  contention,  and  shows  that  there  must  be  some  specific  substances 
which  are  active  in  this  regard.  But  this  has  not  been  proved  con- 
clusively. 

Theoretically,  it  would  be  expected  that  tuberculin,  provoking  the 
same  phenomena  in  the  animal  body  as  the  living  tubercle  bacilli, 
should  also  have  an  immunizing  effect.  But  so  far  nobody  has  been 
successful  in  an  attempt  at  immunization  of  the  body  with  dead 
tubercle  bacilli,  or  any  part  of  the  culture  in  which  they  grow. 
More  satisfactory  results  have  been  obtained  by  infections  with 
living  bacilli. 

Tuberculin  hypersensitiveness  differs  from  anaphylaxis  by  the 
fact  that  in  normal  animals  tuberculin  may  be  injected  in  large  or 
small  amounts,  at  long  or  short  intervals  without  producing  hyper- 
sensitiveness, and  attempts  at  passive  transference  of  tuberculin 
hypersensitiveness  have  led  to  doubtful  results.  Baldwin  has  been 
unable  to  produce  transference,  or  passive  anaphylaxis,  from  tuber- 
culous guinea-pigs  to  healthy  ones,  and  also  from  rabbit  to  rabbit, 
and  from  rabbit  to  guinea-pig.  From  human  to  guinea-pig  the 
results  M^ere  very  doubtful,  but  to  rabbit,  partly  successful.  But 
another  difference  between  anaphylactic  shock  and  tuberculin  hyper- 
sensitiveness may  be  mentioned.  The  former  phenomenon  appears 
immediately  after  an  injection,  while  in  the  latter  they  are  delayed 
for  many  hours;  in  the  former  there  is  a  marked  reduction  in  the 
temperature,  etc.,  while  in  the  latter  the  contrary  is  true. 

Specificity  of  the  Tuberculin  Reaction.— We  have  seen  that  tuber- 
culin produces  obvious  effects  only  in  the  infected  organism.  The 
question  then  arises  whether  the  reaction  it  produces  is  strictly  specific. 
Many  workers  have  found  that  tuberculous  animals  react  to,  and  may 
even  be  kille<l  l)y,  the  injection  of  any  foreign  bacteria  protein  of  non- 
tuberculous  origin  in  the  same  manner  as  by  tuberculin.  In  human 
beings  there  was  also  found  hypersensitiveness  to  non-tuberculous 


POISONS  PRODUCED  BY   THE   TUBERCLE  BACILLI  33 

extracts  from  bacilli  closely  resembling  the  hypersensitiveness  induced 
by  tuberculin.  Even  the  cutaneous  tuberculin  reaction  can  be  pro- 
duced by  non-tuberculous  toxins  inoculated  in  the  same  manner  as 
tuberculin  is  applied  in  the  von  Pirquet  and  other  tests. 

The  changes  in  reactivity  to  tuberculin  may  be  induced  by  non- 
tuberculous  proteins  and  toxins.  The  general  reaction,  the  fever, 
with  concomitant  subjective  symptoms,  such  as  headache,  anorexia, 
etc.,  also  the  local  reaction  at  the  site  of  the  inoculation  and  finally 
even  the  so-called  "focal  reaction"  manifesting  itself  in  the  tuber- 
culous lesion,  have  all  been  produced  by  non-tuberculous  substances. 
On  the  other  hand,  tuberculin  has  produced  these  reactions  in  patients 
suffering  from  leprosy,  syphilis,  etc.  The  suggestion  that  this  does 
not  militate  against  the  specificity  of  the  tuberculin  reaction  because 
these  diseases  may  be  combined  with  tuberculosis,  does  not  explain 
every  case. 

It  has  also  been  found  by  Mettetal^  and  others  that  individuals 
who  react  to  tuberculin  also  react  in  almost  the  same  fashion  to  saline 
solutions,  which  would  indicate  that  it  is  not  necessarily  the  specific 
bodies  in  the  tuberculin  which  are  responsible  for  the  fever,  malaise, 
etc.  At  any  rate,  tuberculin  is  not  the  only  substance  that  produces 
these  phenomena  in  tuberculous  individuals. 

Autopsy  control  has  not  cleared  up  the  problem.  There  have 
been  reported  cases  in  which  a  positive  reaction  was  obtained  during 
life,  but  no  tuberculous  lesions  could  be  discovered  on  careful  dis- 
section of  the  body  after  death,  and  the  reverse.  In  cattle  it  was 
found  that  only  85  to  90  per  cent,  of  those  reacting  to  tuberculin  show 
tuberculous  changes  on  dissection  after  slaughter,  while  10  per  cent, 
of  those  which  do  not  react  show  tuberculous  changes  in  some  organs. 
These  facts  have  important  bearings  on  the  problems  presented  by 
tuberculin  as  a  diagnostic  agent  and  will  be  more  fully  discussed 
later  on. 

Another  problem  arises  when  changed  reactivity  to  tuberculin  is 
found.  Does  it  invariably  indicate  that  the  body  is  at  the  time  harbor- 
ing living  and  virulent  tubercle  bacilli?  Do  individuals  who  have  at 
one  time  passed  through  a  tuberculous  infection,  but  in  whom  the 
lesion  has  completely  cicatrized  also  show  hypersensitiveness  to 
tuberculin?  To  the  first  question  we  have  a  positive  answer — many 
healed  cicatrized  and  calcified  tuberculous  lesions  have  been  found 
to  harbor  virulent  bacilli,  as  has  been  proved  experimentally.  These 
bacilli  are  in  fact  responsible  for  acute  exacerbations  observed  in  quies- 
cent and  latent  tuberculosis;  they  may  also  be  held  responsible  for 
the  onset  of  the  average  case  of  phthisis  in  adults,  as  will  be  shown 
elsewhere.  But  what  is  of  more  importance  is  whether,  once  acquired, 
the  tuberculin  hypersensitiveness  remains  throughout  the  life  of  the 

1  Valeur  de  la  tuberculine  dans  la  diagnostic  de  la  tuberculose  de  la  premiere  enfance, 
Thdse  de  Paris,  1900. 
3 


34  THE   TUBERCLE  BACILLI 

individual.  This  is  a  problem  which  has  not  j^et  been  investigated 
to  an  extent  as  to  warrant  a  positive  answer. 

Outside  of  these  theoretical  considerations,  these  problems  have 
great  practical  bearings  on  the  utility  of  tuberculin  as  a  diagnostic 
agent,  which  is  discussed  in  this  book  in  its  proper  place. 

Mixed  Infection. — Soon  after  the  discovery  of  the  tubercle  bacilli, 
some  investigators,  finding  other  pathogenic  microorganisms  in  the 
secretions  and  excretions  of  phthisical  subjects  have  maintained  that 
the  disease  is  due  to  infection  with  other  bacteria  in  addition  to  the 
specific  germ.  In  fact,  many  authors  of  ten  or  fifteen  years  ago 
maintained  that  the  fever  in  tuberculosis  is  more  the  result  of  infec- 
tion with  pyogenic  organisms  than  with  the  tubercle  bacilli.  The 
fact  that  contents  of  cavities,  as  well  as  their  walls  which  are  often 
covered  with  pyogenic  membranes,  often  contain  influenza  bacilli, 
pneumococci,  streptococci,  staphylococci,  etc.,  would  tend  to  confirm 
this  view.  This  view  is  even  now  held  by  many  authorities.  Thus 
Victor  C.  Vaughan  says:  "Unaided,  the  tubercle  bacillus  seldom  kills, 
but  the  microbic  tissue  caused  by  its  growth  forms  a  suitable  medium 
for  the  lodgement  and  growth  of  other  bacteria  and  tuberculosis  usually 
terminates  as  the  result  of  infection.  So  long  as  the  infection  is 
unmixed,  the  progress  of  the  disease  is  slow."  But  in  acute  miliary 
tuberculosis,  which  is  invariably  fatal,  only  the  specific  microorganism 
is  found. 

Recent  investigations  have  proved  conclusively  that  the  fever  in 
tuberculosis  may  be  produced  solely  by  the  tubercle  bacilli;  indeed, 
an  injection  of  tuberculin  produces  fever.  The  hectic  fever  of  advanced 
phthisis,  which  bears  great  similarity  to  septic  fever  due  to  other 
causes,  may  also  be  the  result  of  pure  tuberculous  activity.  Even 
Inman,  who  through  very  laborious  research  found  a  secondary  infec- 
tion in  all  cases  with  fever  while  the  patient  was  resting  in  bed,  con- 
cludes that  the  tubercle  bacillus  is  almost  invariably  the  predominant 
infective  agent. 

During  the  course  of  phthisis  secondary  infections  are  often 
observed.  A  phthisical  patient  may  be  infected  with  pneumococci 
which  produce  pneumonia,  influenza  bacilli,  producing  grippe,  etc. 
But  this  can  no  more  be  considered  "mixed  infection"  than  the 
association  of  phthisis  with  diphtheria,  gonorrhea,  etc. 

The  streptococci,  staphylococci,  pneumococci,  etc.,  which  are  often 
found  in  tuberculous  cavities  may,  and  often  do,  influence  the  symp- 
tomatology, course  and  termination  of  the  disease,  but  in  incipient 
cases  the  microorganism  which  is  responsible  for  the  disease  is  only 
the  tubercle  bacillus. 


CHAPTER  II. 
TUBERCULOUS  INFECTION. 

The  Problems  of  Infection. — With  the  discovery  of  the  tubercle 
bacillus  in  1882  it  was  at  once  concluded  that  practically  all  the 
problems  of  phthisiogenesis  had  been  settled.  The  infective  agent, 
the  bacillus,  enters  the  human  body,  implants  itself  in  some  tissue; 
by  its  growth  and  metabolic  processes  it  produces  toxic  symptoms 
and,  causing  caseation  and  liquefaction,  destroys  vital  organs,  etc. 
With  this  knowledge,  it  was  thought  that  the  prevention  of  the  disease 
had  been  reduced  to  simple  principles:  The  destruction  of  the  bacilli 
wherever  found;  and  the  prevention  of  their  entry  into  the  human 
body  when  attempts  at  their  destruction  fail  for  any  reason. 

To  destroy  the  bacilli  it  was  necessary  to  ascertain  all  the  places 
where  they  are  found  in  nature.  This  was  apparently  an  easy  matter. 
We  know  that  the  tubercle  bacillus  is  a  strict  parasite,  living  and 
multiplying  only  in  the  human  and  animal  body.  Investigations 
by  Sander  tend  to  show  that,  within  certain  limits,  they  can  prohferate 
on  vegetable  media  during  the  hot  summer  months,  but  it  is  problem- 
atical whether  this  mode  of  life  explains  any  infection  in  man. 
After  the  facts  gathered  in  investigations  are  taken  into  consideration, 
there  is  no  doubt  that  the  only  suitable  soil  for  life,  growth  and  multi- 
plication for  this  bacillus  is  the  animal  body,  and  that  the  secretions 
and  excretions  of  diseased  persons  and  animals  are  the  only  means 
of  disseminating  the  disease. 

We  have  shown  that  bacteriologists  have  distinguished  at  least 
four  main  types  of  pathogenic  tubercle  bacilli:  the  human,  the 
bovine,  the  avian,  and  the  reptilian.  Practical  experience  has  shown 
that  the  last  two  types,  those  of  birds  and  of  cold-blooded  animals, 
play  no  role  in  the  epidemiology  of  tuberculosis  in  human  beings, 
at  least  not  a  very  significant  role.  There  are  consequently  left  the 
human  and  bovine  types  to  be  considered  as  etiologically  important 
in  tuberculosis  in  human  beings. 

Careful  investigations  by  Theobald  Smith,  William  H.  Park,  A.  S. 
Griffith,  Eraser,  The  British  Royal  Commission,  The  German  Imperial 
Health  Board,  and  others  have  shown  that  more  than  99  per  cent, 
of  phthisis  in  adults  and  about  85  to  90  per  cent,  of  serious  tuberculous 
disease  in  children  is  due  to  the  human  type  of  bacillus;  that  the 
bovine  type  is  found  in  about  10  per  cent,  of  tuberculosis  in  children 
and  in  phthisis,  this  type  is  so  exceptional  as  to  make  each  case  worthy 
of   careful  reporting.      It  also  appears  from  the  evidence  thus  far 


36  TUBERCULOUS  INFECTION 

gathered  that  tuberculosis  in  children  due  to  bovine  bacilli  is  mostly 
of  the  milder  forms  of  the  disease — surgical  tuberculosis,  of  the  gland- 
ular systems,  especially  of  the  thoracic  and  the  abdominal  glands, 
of  the  joints,  bones,  and  skin.  In  other  words,  the  tuberculosis  caused 
by  the  ingestion  of  bacilli  with  milk  from  tuberculous  cows  is  not  of 
great  significance,  except  perhaps  in  infants,  when  compared  with  the 
immensity  of  the  problems  presented  by  infections  with  the  human 
type  of  bacilli  causing  phthisis  in  adults  and  fatal  tuberculosis  in 
infants. 

For  these  reasons  some  authors  have  stated  that  bovine  infections 
may  be  disregarded;  only  infection  with  bacilli  acquired  through 
the  entn'  of  tubercle  bacilli  which  have  been  incubated,  so  to  say, 
in  tuberculous  human  beings,  is  to  be  combated,  if  phthisis  is  to  be 
eradicated  at  all.  The  corollary  to  be  drawm  is  that  the  sources  of 
the  tubercle  bacilli  are  mainly  human  consumptives. 

Mutation  of  the  Types  of  Bacilli. — Further  study  has,  however, 
complicated  this  problem.  It  has  been  suggested  by  many  authors, 
notably  Orth,^  Rabinowitsch,  Beitzke,  ]\Iuch,  and  others  that  bovine 
bacilli,  remaining  in  the  human  body  for  a  long  time  and  adapting 
themselves  to  the  surroundings,  may  accpire  the  characteristics  of  the 
human  type,  a  kind  of  biological  transformation  of  type,  or  mutation. 
It  is  clear  that  in  our  attempts  at  eradication  of  phthisis  this  problem 
is  of  immense  importance.  The  10  per  cent,  or  more  of  children  in 
civilized  countries  who  are  infected  during  childhood  with  milder 
forms  of  tuberculosis  thus  harbor  the  bovine  bacilli  within  their 
bodies  for  many  years,  during  which  time  they  adapt  themselves  to 
the  surroundings,  and  when  they  cause  phthisis  in  the  adult  we  find 
them  with  the  characteristics  of  the  human  type. 

In  support  of  this  assertion  it  was  sho^^Ti  that  very  often  "atypical" 
bacilli  are  found  in  cases  of  tuberculosis;  they  are  microorganisms 
which  cannot  be  classed  with  either  the  human  or  the  bovine  type. 
They  have  been  called  "transitional"  t^'pes;  t^'pes  which  may  have 
been  originally  bovine,  but  after  sojourning  in  the  human  body  for 
some  time  are  on  the  way  to  acquiring  traits  of  human  bacilli. 

The  British  Royal  Commission  says  in  this  connection  that  they 
"are  inclined  to  regard  transmutation  of  the  bacillary  type  as  exceed- 
ingly difficult,  if  not  impracticable,  of  accomplishment  by  laboratory 
procedure;  though  in  view  of  certain  instances  in  which  we  obtained 
from  one  and  the  same  human  body  both  types  of  bacillus,  we  are  not 
prepared  to  deny  that  transmutation  of  one  type  into  another  may 
occur  in  nature."  Theobald  Smith-  also  says  that  "the  time  has  not 
yet  come  for  us  to  state  positively  that  one  type  cannot  be  transformed 
into  another."  Arloing,  Marcus  Robinowitsch,  Sorgo,  Musemeier, 
Dammann,  and  others  have  in  fact  ])een  able  to  proihicc  changes 
in  the  morphological  and  cultural  characters,  and  in  the  xirulcncc  of 

1  Droi  Vortiiigo  u})ct  Tuhorkulose,  Berlin,  1913. 
•  Sixth  Interu.  Congr.  Tuberc,  1908,  iv,  651. 


THE  CHANNELS  OF  THE  ENTRY  OF  TUBERCLE  BACILLI     37 

bacilli  by  passage  through  various  animals,  or  cultivating  them  in 
different  media.  But  Park  and  Krumwiede'^  say:  "We  have  carefully 
examined  the  reports  of  numerous  workers  on  this  point,  and  cannot 
admit  that  the  evidence  for  the  transformation  of  type  is  complete." 
Theobald  Smith,  after  studying  the  evidence  also  arrives  at  the  con- 
clusion that  "in  general  the  results  of  these  passages  have  been  nega- 
tive so  far  as  any  recognizable  modification  of  type  is  concerned." 
Park's  suggestion  that  the  change  in  type  observed  after  passing 
through  a  series  of  animals  is  due  to  additional  bovine  infection, 
has  a  great  deal  in  its  favor.  Cases  in  which  both  types  were  found 
in  human  beings  have  been  reported. 

We  are  therefore  justified  in  concluding  with  Park  and  Krumwiede 
that  "the  two  types  are  probably  different,  due  to  residence  in  different 
hosts  over  long  periods  of  time,  and  as  such  are  stable.  The  evidence 
of  rapid  change  is  incomplete  and  inconclusive."  In  the  human 
disease  the  stability  of  type  is  apparently  beyond  question.  Some 
cases  have  been  followed  for  long  years  and  the  type  of  the  bacillus 
has  been  found  to  be  unaltered.  Weber  and  Steft'enhagan  have  followed 
for  ten  and  a  half  years  a  case  of  surgical  tuberculosis  and  always 
found  bovine  bacilli,  without  changing  their  typical  characteristics. 

The  weight  of  evidence  is  thus  in  favor,  of  human  phthisis  being 
due  almost  exclusively  to  human  bacilli,  and  that  infection  during 
childhood  with  bovine  bacilli  cannot  be  held  responsible  for  phthisis 
in  the  adult,  because  it  has  not  been  proved  that  mutation  of  one 
type  into  another  takes  place. 

The  main  source  of  the  bacilli  causing  phthisis  in  the  adult,  and 
serious  or  fatal  tuberculosis  in  infants  or  children,  appears  to  be  the 
tuberculous  man  who  expectorates  myriads  of  bacilli  fit  for  entering 
healthy  persons  and  causing  disease. 

The  Channels  of  Entry  of  the  Tubercle  Bacilli.— It  is  obvious  that 
in  order  to  prevent  phthisis,  the  ways  in  which  the  bacilli  enter  the 
human  body  must  be  known  definitely.  To  the  average  person, 
lay  or  medical,  who  has  informed  himself  from  current  popular  litera- 
ture, this  question  has  been  answered  satisfactorily:  if  the  bacilli 
are  derived  from  human  sources,  they  have  usually  been  inhaled;  if 
from  bovine  sources  they  have  been  ingested. 

But  it  may  be  stated  without  fear  of  meeting  contradiction  from 
competent  sources  that  this  problem  has  not  yet  been  solved  to  the 
satisfaction  of  all  who  are  entitled  to  an  opinion.  Romer,^  one  of  the 
most  active  experimental  workers  in  the  field  of  tuberculosis,  and 
one  of  those  best  qualified  to  speak,  says  that  none  of  the  given  channels 
of  entry  of  the  tubercle  bacilli  is  alone  sufficient  to  adequately  solve 
all  and  the  complete  problems  of  tuberculous  infection. 

There  are  three  evident  portals  of  entry  which  are  always  mentioned 

1  Trans.  Sixth  Ann.  Meet.  Nat.  Assn.  Study  and  Preven.  Tuberc,  1910,  p.  332;  Jour. 
Med.  Research.  1911,  xx,  313;    1912,xxii,  109. 

2  In  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  der  Tubcrkulose,  1914,  i,  247. 


38  TUBERCULOUS  INFECTION 

as  possible:  Inhalation  through  the  respiratory  passages;  ingestion 
through  the  digestive  tract;  inoculation  into  the  skin  or  mucous 
membranes.  While  each  of  the  three  modes  of  infection  has  been 
shown  to  be  possible,  and  proved  experimentally  and  clinically,  the 
inhalation  channel  has  been  considered  the  most  important  in  the 
case  of  human  phthisis.  Ingestion  may,  however,  be  found  of  greater 
importance  than  it  is  now  considered. 

Contact  Infection. — The  inoculation  of  the  tuberculous  virus  into 
the  skin  and  mucous  membranes  may  cause  disease.  This  has  been 
proved  beyond  any  doubt  both  experimentally  and  clinically.  In- 
oculated tuberculosis  is  most  virulent  during  infancy;  the  younger 
the  child,  the  more  serious  the  outcome.  The  "pathologist's  wart" 
and  the  "butcher's  wart"  in  the  adult  are  not  very  malignant  diseases, 
while  infection  of  the  wound  during  ritual  circumcision  is  almost 
invariably  fatal,  as  has  been  observed  by  many  authors,  and  more 
recently  by  Holt.^  The  reasons  for  these  differences  in  virulence  will 
be  discussed  later  on. 

Sputum  from  tuberculous  patients  is  infective  in  another  way. 
It  enters  the  circulation  through  an  abrasion.  In  overcrowded  and 
filthy  homes,  where  children  creep  around  on  the  floors  on  which 
consumptives  have  expectorated,  this  mode  of  infection  is  undoubtedly 
quite  frequent.  Baldwin^  and  others  found  virulent  tubercle  bacilli 
on  the  fingers,  and  under  the  nails  of  consumptives,  as  well  as  of 
those  who  live  with  them.  It  has  also  been  established  that  under 
exceptional  circumstances  infection  is  possible  through  the  unbroken 
skin  of  animals. 

Skin  infections  produce  local  lesions  at  the  point  of  entry  of  the 
bacilli,  and  in  infancy  a  fatal  bacteremia  may  be  the  result.  But  when 
cutaneous  skin  affections  such  as  lupus  vulgaris,  tuberculosis  verru- 
cosa cutis,  or  the  so-called  tuberculides  are  considered,  it  must  not 
be  concluded  that  they  have  invariably  been  acquired  by  local  infec- 
tion. As  will  be  shown  later  on,  while  discussing  the  aerogenic  and 
hematogenic  origin  of  tuberculosis,  the  bacilli  may  have  been  brought 
to  the  skin  by  the  blood  stream.  This  has  in  fact  been  found  in  most 
cases.  It  is  noteworthy  in  this  connection  that  phthisis  occurs  only 
exceedingly  rarely  in  patients  with  lupus  and  other  tuberculous  skin 
affections.  Some  have  spoken  of  an  immunity  against  tuberculosis 
possessed  by  these  patients.  The  reverse  also  appears  to  be  true — 
tuberculous  skin  disease  is  rare  in  phthisical  patients,  and  when  we 
bear  in  mind  the  opportunities  for  infection  we  are  justified  in  speak- 
ing of  immunity. 

On  the  whole  it  appears  that  Romer  is  on  a  sound  foundation  when 
he  says  that  the  problem  of  infection  through  the  skin  has  not  yet 
been  studied  sufficiently,  and  with  our  present  knowledge  we  are 


1  Jour.  Amer.  Med.  Assn.,  1913,  Ixi,  99. 

2  Trans.  Amer.  Climat.  Assn.,  1908,  xiv,  202. 


INFECTION  BY  INHALATION  OF  BACILLI  39 

not  in  a  position  to  state  with,  any  degree  of  certainty  its  importance 
as  a  factor  in  the  spread  of  the  disease. 

Infection  by  Inhalation  of  the  Bacilli.— That  the  virus  of  tubercu- 
losis is  inhaled  with  the  inspired  air  has  been  asserted  for  centuries 
by  physicians,  and  Villemin  suggested  this  mode  of  infection  after 
his  experimental  investigations.  But  Koch  and  his  pupil  Cornet^ 
were  tlie  first  to  prove  that  dust  containing  tubercle  bacilli  derived 
from  dessicated  sputum  is  highly  infectious  to  guinea-pigs.  Cornet's 
experiments  with  dried  sputum  scattered  over  a  carpet  on  which  the 
animals  were  compelled  to  live  while  the  carpet  was  often  swept 
with  a  stiff  broom,  has  remained  classical  and  is  often  quoted  as 
proving  conclusively  the  dangers  lurking  in  dried  sputum  in  the 
average  dwelling  inhabited  by  careless  consumptives.  On  the  basis 
of  such  experiments  rested  the  entire  inhalation  hypothesis  of  tuber- 
culous infection. 

The  fact  that  diffuse  daylight,  especially  sun-rays,  kills  tubercle 
bacilli  and  soon  renders  them  avirulent  would  largely  exclude  infection 
through  sputum  deposited  in  the  street  and  even  in  large,  bright 
sunny  rooms.  But  the  average  consumptive,  derived  as  he  is  from 
the  poorer  strata  of  population,  and  living  in  a  squalid  dwelling  lacking 
sufficient  light,  may  deposit  sputum  which  retains  its  virulence  for 
a  long  time. 

Many  valid  objections  have  been  raised  against  the  theory  that 
dessicated  tuberculous  sputum  is  the  main  source  of  infection  in  man. 
Fliigge^  and  many  others  have  shown  that  in  the  ordinary  course 
of  human  events  things  are  not  as  simple  as  stated  by  Cornet  and 
Koch.  The  experiments  with  the  carpet  are  not  altogether  analogous 
to  the  conditions  found  in  human  dwellings,  and  by  no  means  prove 
that  infection  is  acquired  mainly  through  the  inhalation  of  dust  laden 
with  dried  tuberculous  sputum.  Such  large  quantities  of  sputum  as 
were  used  by  Cornet  in  his  experiments  on  guinea-pigs  are  exceedingly 
rarely,  if  ever,  found  in  the  most  squalid  of  dwellings.  It  is  also 
doubtful  whether  dust  laden  with  virulent  tubercle  bacilli  is  often 
raised  to  the  height  of  the  human  head  to  be  inhaled  in  sufficient 
amount  to  infect  even  while  the  floor  is  being  swept. 

In  fact,  further  investigations  by  Fliigge,  Neisser,  Kohlisch,  and 
others  have  not  yielded  the  same  results  as  those  reported  by  Koch, 
Cornet  and  their  followers.  It  was  found  that  in  houses  inhabited 
by  consumptives  the  sputum  deposited  on  the  floors  is  not  often 
perfectly  dried  and  thinly  pulverized,  capable  of  rising  with  the  dust 
to  the  height  of  five  or  more  feet  from  the  ground.  Moreover,  con- 
ditions in  unsanitary  homes  are  not  conductive  in  the  direction  of 
drying  the  sputum  soon  after  it  has  been  eliminated  by  the  consumptive. 
And  if  it  takes  time  to  dry,  it  must  be  remembered  that  the  bacilli 
lose  their  virulence  within  ten  days  owing  to  putrefactive  processes 

1  Verhandl.  Berlin,  med.  Gesellsch.,  1899,  xxx,  91. 

2  Zeitschr.  f.  Hygiene  u.  Infektionskr.,  1909,  xxx,  107. 


40  TUBERCULOUS  INFECTION 

on  the  floors  of  filthy  houses,  and  the  diffuse  hght  which  acts  during 
the  day,  or  artificially  during  the  night.  It  is  also  noteworthy  in  this 
connection  that  in  the  average  house  there  are  no  air  currents  strong 
enough  to  raise  the  dust  to  the  height  of  about  five  feet. 

It  may  seem  incredible,  yet  it  is  a  fact  that  it  is  exceedingly  rare 
to  find  a  house  where  proper  precautions  are  taken  as  to  expectoration 
in  which  the  collected  dust  shows  virulent  tubercle  bacilli.  Even  in 
houses  inhabited  by  consumptives — sanatoriums,  dispensaries,  railroad 
stations,  factories,  cars,  etc. — no  dust  containing  virulent  tubercle 
bacilli  has  been  found  in  most  cases  investigated.  Thus,  Kohlisch^ 
could  not  infect  guinea-pigs,  which  are  very  susceptible,  wdth  dust 
collected  in  houses  inhabited  by  consumptives;  Wagner  collected 
dust  in  a  sanatorium  at  Zurich,  in  such  places  in  which  the  air  stream 
could  have  brought  it,  and  injected  it  intraperitoneally  into  guinea- 
pigs  and  found  that  in  only  3.5  per  cent,  of  cases  did  infection  take 
place.  Even  in  Chausse's^  investigations  of  the  dust  in  the  tuberculosis 
wards  of  the  Hospital  Boucicaut  in  Paris,  where  conditions  are  such 
as  to  favor  bacterial  life,  only  seven  out  of  eighteen  specimens  showed 
the  presence  of  virulent  bacilli.  Dust  collected  in  the  streets  hardly 
ever  shows  the  presence  of  living  tubercle  bacilli. 

Infection  under  "  Natural"  Conditions. — In  a  review  of  the  hterature 
on  this  subject,  Charles  V.  Chapin^  says:  "Although  there  has  been  a 
vast  amount  of  experimental  work  on  infection  in  tuberculosis,  there 
has  been  very  little  in  which  conditions  at  all  approached  the  natural. 
Usually  there  is  an  excessive  amount  of  exposure,  or  an  excessive 
number  of  germs  in  spray  or  dust.  Thus,  in  Cornet's  notable  experi- 
ment, where  47  of  48  guinea-pigs  were  infected  by  breathing  dust, 
the  carpet  has  been  smeared  with  large  quantities  of  sputum,  and  it 
was  forcibly  beaten  so  that  clouds  of  dust  rose  up  directly  in  front  of 
the  animal.  It  is  surprising  that  so  few  have  thought  it  worth  while 
to  see  how  infection  takes  place  in  animals  kept  under  conditions 
as  nearly  as  possible  like  those  under  which  human  beings  live." 

At  Dr.  Chapin's  suggestion,  M.  S.  Packard  carried  out  an  experi- 
ment with  a  view  of  determining  the  mode  of  infection  under  "  natural 
conditions."  Two  sets  of  guinea-pigs  were  exposed  in  a  house  occupied 
by  a  careless  consumptive.  They  were  exposed  in  cages,  one  set  fed 
by  the  patient  and  the  other  excluded  from  any  possible  form  of 
contact.  Most  of  the  animals  in  both  sets  developed  tuberculosis. 
Chapin  suggests  that  the  animals  kept  in  the  locked  cage  covered 
with  wire  gauze  were  infected  by  mouth  spray,  as  the  patient  often 
held  his  face  right  in  front  of  the  box  and  talked  to  the  animals. 

Other  experiments  along  these  lines  were  performed  by  Schroeder 
and  Cotton.-^    They  exposed  7  cows  in  adjoining  stalls  to  3  tuberculous 

1  Zeitschr.  f.  Hyg.  u.  Infektionskr.,  190S.  Ix,  .508. 

2  Ann.  Inst.  Pasteur,  1914,  xxviii,  720,  771. 

s  The  Sources  and  Modes  of  Infection,  p.  309. 

4  Report  Bureau  of  Animal  Industry,  1900,  xxiii,  31. 


DROPLET  INFECTION  41 

cows,  and  found  that  6  contracted  the  disease.  They  also  exposed 
100  guinea-pigs  in  the  stalls,  50  in  cages  below  the  mangers  where  food 
could  sift  through  from  the  mangers,  and  50  on  the  walls.  They 
also  exposed  35  guinea-pigs  for  one  hundred  and  thirty-five  days 
on  the  walls  of  the  stalls.  Only  2  developed  tuberculosis.  Of  42 
animals  kept  for  fifty-one  days  under  the  manger  of  infected  cows, 
6  developed  tuberculosis  of  an  acute  and  general  type. 

There  are  some  points  to  be  borne  in  mind  when  evaluating  the 
bearings  of  these  experiments  on  spontaneous  human  infection. 
Guinea-pigs  and  cattle  are  more  susceptible  to  infection  with  tubercle 
bacilli  than  are  humans,  and  after  all  the  experiments  were  not  alto- 
gether in  conformity  with  conditions  in  human  dwellings.  Even 
Bartel  and  Spieler's^  and  other  attempts  to  simulate  conditions  in 
human  contact  of  tuberculous  with  non-tuberculous  fail  when  critically 
examined.  It  is  also  a  fact  that  cattle,  guinea-pigs,  and  other  animals 
are  "virgin  soil,"  while  human  beings  above  the  age  of  fifteen  have 
mostly  been  immunized  by  a  previous  mild  infection.  Virgin  soil  is 
easily  infected,  as  was  repeatedly  shown.  There  are  many  cases  on 
record  in  which  cows  in  whom  the  only  manifestation  of  tuberculous 
infection  was  that  they  were  "reactors,"  and  were  introduced  into 
stables  with  other  cows  which  did  not  react  to  tuberculin.  The  latter 
were  soon  infected,  becoming  "reactors,"  though  as  far  as  could  be 
ascertained  the  first  infected  cows  did  not  excrete  any  tubercle  bacilli. 
This  would  indicate  that  infection  can  be  accomplished  in  some  manner 
with  which  we  are  as  yet  unacquainted. 

Droplet  Infection. — It  is  obvious  that  though  infection  through 
the  inhalation  of  dust  containing  desiccated  tuberculous  sputum  is 
undoubtedly  possible,  this  is  not  the  only  or  the  most  common  mode 
of  spontaneous  infection  of  human  beings  under  "natural  conditions," 
and  many  have  maintained  that  in  the  vast  majority  of  cases  infec- 
tion is  accomplished  directly  from  one  person  to  another.  The  moist 
droplets  eliminated  by  consumptives  while  speaking  and  especially 
while  coughing  and  sneezing,  may  be  inhaled  by  persons  who  happen 
to  be  in  their  proximity.  Fliigge^  and  his  followers,  who  have  done 
considerable  experimental  work  along  these  lines,  are  satisfied  that 
under  natural  conditions  the  dissemination  of  tuberculosis  from  man 
to  man,  "droplet  infection,"  is  the  most  common  mode. 

Careful  research  has  shown  that  the  air  exhaled  by  consumptives 
during  ordinary  and  quiet  breathing  is  free  from  tubercle  bacilli, 
but  the  moist  droplets  eliminated  from  the  mouth  while  talking, 
coughing,  sneezing,  etc.,  do  often  contain  tubercle  bacilli  wdiich  may 
remain  floating  in  the  air  for  some  time.  Indeed,  it  has  been  found 
that  the  Bapillus  prodigiosus  may  thus  float  in  the  air  for  five  hours. 
But  this  will  hardly  hold  for  the  tubercle  baciflus.     After  holding  a 

'  Wiener  klinische  Wchnsehr.,  1905,  xviii,  218. 

2  Die  Verbi-eitungsweise  und  Bekiimpfung  der  Tuberkulose  auf  Grund  expcrimcnteller 
Untersuchungen,  Leipzig,  1908. 


42  TUBERCULOUS  INFECTION 

cover-glass  in  front  of  a  coughing  consumptive,  tubercle  bacilli  "^'ere 
found  microscopically  as  well  as  by  inoculation  experiments  which 
were  positive  in  90  per  cent,  of  cases.  In  many  cases  bacilli  were 
deposited  on  the  cover-glasses,  which  were  held  at  a  distance  of  from 
40  to  80  cm.  from  the  patient's  mouth.  The  infectiousness  of  these 
droplets  was  confirmed  by  experiments  of  Heymami^  who  exposed 
guinea-pigs  in  front  of  coughing  consumptives. 

These  experiments  were  apparently  more  often  positive  than  in 
the  case  of  infection  with  dust  containing  desiccated  tuberculous 
sputum,  and  Fliigge  and  his  followers  conclude  that  this  mode  of 
infection  is  the  most  important  under  natural  conditions. 

But  even  these  experiments  are  open  to  question.  The  animals 
were  held  tightly  for  hours  directly  exposed  to  the  faces  of  the  con- 
sumptives who  coughed  directly  into  their  open  mouths.  Such  ex- 
posure never  occurs  in  human  beings,  except  perhaps  in  cases  of 
tuberculous  mothers  holding  their  crying  babies  on  their  arms  and 
coughing  directly  into  their  open  mouths,  which  may  be  observed 
now  and  then  among  certain  classes,  but  after  all  camiot  be  considered 
very  common. 

Even  conceding  that  droplet  infection  is  an  important  mode  of 
transmission  of  tuberculosis,  it  must  be  realized  that  it  depends  on 
many  factors  which  are  not  always,  nor  even  often,  operative.  It 
has  been  found  that  when  a  healthy  person  is  at  a  distance  of  three 
feet  from  the  coughing  patient,  the  droplets  will  not  reach  far  enough 
to  become  a  possible  infective  agent  excepting  perhaps  when  carried 
by  air  currents.  Another  important  factor  is  the  dose  of  the  bacilli 
that  may  thus  be  inhaled.  It  has  been  shown  that  small  numbers 
of  bacilli  are  easily  taken  care  of  by  the  human  organism.  It  is  also  a 
fact  that  tubercle  bacilli  thus  eliminated  do  not  remain  floating  in  the 
air  for  any  length  of  time,  but  sink  to  the  floor  where  they  are  soon 
rendered  innocuous,  as  was  already  mentioned. 

It  is  thus  obvious  that  only  when  contact  with  the  consumptive 
is  very  close,  intimate,  and  prolonged,  which  in  ordinary  life  occurs, 
as  a  rule,  only  in  mothers  with  suckmg  infants,  or  between  husband 
and  wife,  droplet  infection  may  become  a  serious  menace.  And  even 
in  these  cases  there  are  natural  safeguards. 

Considering  the  evidence  thus  far  brought  together  at  its  face  value, 
it  appears  that  inhalation  of  dust  containing  tuberculous  sputum, 
or  of  droplets  expelled  by  consumptives  while  talking,  coughing,  and 
sneezing,  may  infect  a  healthy  person,  yet  the  evidence  that  these 
are  the  most  frequent  modes  of  the  dissemination  of  tuberculosis  is 
inadequate.  Behring  and  Chapin  have  aptly  pointed  out  that  there  has 
been  a  strong  tendency  among  medical  men  of  all  ages  to  attribute 
the  transmission  of  infectious  diseases  of  obscure  causation  to  the  inha- 
lation of  the  virus.    This  has  notably  been  the  case  with  the  endemic 

^  Quoted  from  Fliigge. 


NATURAL  BARRIERS  AGAINST  INHALATION  INFECTION     43 

diseases  of  childhood,  and  for  a  long  time  yellow  fever,  typhoid, 
typhus,  malaria,  relapsing  fever,  etc.,  were  all  considered  inhala- 
tion diseases  and  proofs  were  at  hand  to  substantiate  these  con- 
tentions. Recently  more  exact  studies  have  shown  conclusively  in 
some,  and  with  a  high  degree  of  probability  in  others,  that  they  are 
altogether  transmitted  through  the  agency  of  certain  insects.  Indeed, 
physicians  of  a  few  generations  ago  drew  analogies  between  tuber- 
culosis and  malaria,  typhus,  etc.,  showing  that  they  were  all  caused 
by  the  inhalation  of  the  virus. 

Natural  Barriers  against  Inhalation  Infection. — Notwithstanding 
the  various  disharmonies  which  may  be  found  in  the  structure  and 
functions  of  the  human  body,  and  which  Metchnikoff  has  so  cleverly 
enumerated  in  one  of  his  books,  the  respiratory  tract  is  provided  with 
a  most  wonderful  protective  apparatus  for  the  prevention  of  the 
entry  and  implantation  of  bacilli  in  the  deeper  respiratory  passages. 
Indeed,  no  organ  in  the  body,  excepting  the  central  nervous  system, 
is  fitted  out  with  better  safeguards  in  this  regard. 

The  bacilli  cannot  enter  the  lungs  with  ease.  The  nasal  passages, 
mouth  and  throat  act  as  excellent  filters,  detaining  the  inhaled  dust. 
Even  when  some  microorganisms  in  the  inhaled  air  pass  all  the  barriers, 
the  mucus  secreted  all  along  the  tract,  the  ciliated  epithelium,  etc., 
soon  remove  them  as  foreign  bodies  when  necessary,  assisted  by 
cough,  which  has  the  function  of  clearing  the  lungs.  The  few  bacilli 
which  may  remain  within  for  any  reason  are  under  normal  conditions 
well  cared  for  by  the  extensive  lymphatic  apparatus  which  surrounds 
all  the  bronchi  and  bloodvessels  and  takes  up  bacteria,  destroying 
them  or  at  least  rendering  them  innocuous.  From  animal  experiments 
conducted  for  years  by  Bacmeister^  he  shows  that  while  tubercle 
bacilli  are  only  rarely  found  in  the  lungs  of  animals  compelled  to 
inhale  dust  containing  the  germs,  he  never  observed  that  infection 
of  the  normal  lung  should  be  caused  in  this  manner,  and  he  concludes 
that  the  bacilli  must  be  hindered  in  their  development,  destroyed  or 
carried  away  from  the  lungs  by  the  lymph  and  blood  stream.  There 
is  no  reason  against  the  assumption  that  the  normal  human  lung 
acts  in  the  same  manner  and  that  small  numbers  of  bacilli  which  may 
succeed  in  penetrating  into  deep  air  vesicles  are  removed  or  destroyed 
before  they  can  gain  a  foothold  and  cause  disease. 

It  must,  however,  be  borne  in  mind  that  dust  of  any  kind  may  and 
does  reach  the  lungs  with  the  inspired  air,  as  is  evident  from  the 
large  numb.er  of  cases  of  pneumokoniosis  of  various  degrees.  Tubercle 
bacilli  may  thus  be  brought  there  with  the  inspired  air.  But  whether 
they  cause  disease  in  every  case  they  reach  the  lungs  is  a  disputed 
problem,  the  weight  of  evidence  being  against  such  a  contention. 
Indeed  it  has  been  proved  that  tubercle  bacilli  may  remain  alive  and 
virulent  in  the  tracheobronchial  glands  for  years  without  causing 

1  Die  Entstehung  der  menschlichen  Lungenphthise,  Berlin,  1914. 


44  TUBERCULOUS  INFECTION 

disease,  or  even  changes  in  the  glands.  Investigations  by  Bartel 
and  Weichselbaum,  Harbitz  and  others  have  shown  that  this  is  fre- 
quently the  case,  and  it  explains  the  latency  of  tuberculosis  in  many 
cases. 

That  tubercle  bacilli  on  mucous  membranes  are  not  invariably 
causing  disease  is  proved  by  another  fact.  These  microorganisms 
have  been  found  on  the  mucous  membranes  of  the  nose,  throat  and 
mouth  of  healthy  individuals.  Noble  W.  Jones^  found  them  in  the 
nasal  cavities  of  healthy  persons  in  the  ordinary  walks  of  life,  espe- 
cially those  who  cared  for  consumptive  patients.  Strauss^  found 
tubercle  bacilli  in  the  nasal  cavities  of  healthy  individuals  living  in 
houses  inhabited  by  phthisical  patients.  Alexander^  found  them  in 
very  large  numbers  on  the  mucous  membranes  of  patients  suffering 
from  ozena,  but  who  had  no  symptoms  or  signs  of  tuberculosis.  These 
facts,  taken  in  connection  with  the  fact  that  tuberculosis  of  mucous 
membranes  of  the  pharynx,  nose  and  mouth  is  exceedingly  rare  even 
in  consumptives,  show  that  these  structures  possess  a  certain  natural 
resistance  against  tuberculosis.  That  it  is  not  solely  due  to  the  immu- 
nity acquired  by  previous  tuberculous  infection  is  shown  by  the  fact 
that,  as  a  primary  infection,  tuberculosis  of  these  parts  is  exceedingly 
rare,  though  it  must  be  admitted  that  while  entering  the  body,  by 
inhalation  or  ingestion,  the  bacilli  must  pass  them. 

A  lymphatic  apparatus  of  normal  structure  and  function  evidently 
insures  against  the  implantation  of  all  kinds  of  bacilli  in  the  respira- 
tory passages.  Otherwise  we  would  all  succumb  to  various  diseases, 
including  tuberculosis.  It  is  only  when  the  natural  protective  forces 
fail  that  tuberculous  infection  may  be  caused  in  this  manner. 

On  the  other  hand,  it  must  be  emphasized  that  the  lungs  are  very 
much  exposed  to  infection  from  the  blood  stream,  and  hematogenic 
infection  may  easily  localize  itself  in  these  organs.  The  lungs  are  the 
first  filter  for  everything  that  may  be  carried  by  the  venous  circulation. 
When  the  lymphatic  apparatus  is  injured  by  anthracosis,  which  is 
very  frequent  in  city  dwellers,  it  is  not  capable  of  removing  tubercle 
bacilli  which  may  be  brought  to  them  with  the  blood  stream.  The 
apices  are  also  located  in  an  especially  unfavorable  position  and  do 
not  move  with  the  respiratory  activity  as  well  as  the  lower  parts, 
and  when  to  this  are  added  an  ossified  costal  cartilage  and  a  short 
first  rib,  we  have  everything  favorable  for  the  localization  of  bacilli 
in  the  apices  (see  Chapter  IV). 

Difficulties  in  the  Way  of  Establishing  the  Portals  of  Entry  of 
Tubercle  Bacilli. — The  reasons  why  experimental  investigations  have 
failed  to  adequately  solve  the  problems  of  the  aerogenic  etiology  of 
phthisis  are  evident  when  we  bear  in  mind  that  pulmonary  tuberculosis, 
as  met  with  in  human  beings,  showing  isolated  foci  which  extend 

1  Med.  Record,  1900,  Iviii,  285. 

2  Bull,  de  I'Acad.  de  Med.,  Paris,  1894,  xxxii,  ii,  18. 

3  Berl.  klin.  Wchnschr.,  1903,  xl,  508. 


HEMATOGENIC  INFECTION  45 

slowly  downward  in  the  lungs,  never  occurs  spontaneously  in  animals; 
nor  has  it  ever  been  induced  artificially  or  experimentally  in  animals. 

Real  active  initial  lesions  in  the  human  lungs  have  only  rarely  been 
encountered  at  necropsies.  Most  cases  examined  on  the  autopsy 
table  are  advanced  and  it  is  very  difficult,  or  impossible,  to  decide 
which  was  the  initial  lesion.  Even  the  few  initial  lesions,  found  in 
cases  that  have  died  from  causes  other  than  tuberculosis,  and  reported 
by  Schmorl,^  Birch-Hirschfeld,^  Lubarsch,^  Beitzke,*  and  others 
have  not  cleared  up  definitely  the  problem  whether  the  bacilli  were 
brought  to  the  site  of  the  lesion  by  the  inspired  air  or  the  blood  stream. 
It  has,  however,  been  found  that  even  at  that  stage  both  the  bron- 
chioles and  the  bloodvessels  were  affected  to  such  an  extent  that  either 
or  both  could  be  considered  the  portal  of  entry. 

The  fact  that  the  regional  lymphatic  glands  and  lymph  nodes  are 
usually  implicated  at  an  early  stage  points  to  a  hematogenic  localiza- 
tion, but  it  maj  also  be  explained  by  the  aerogenic  hypothesis. 

It  is  obvious  that  the  inhalation  of  the  bacilli  does  not  exclude 
hematogenic  distribution  and  their  final  localization  at  some  point 
distant  from  the  point  of  entry.  Ribbert,  Bacmeister,  Lubarsch 
and  others  have  pointed  out  that  microorganisms  brought  into  the 
bronchial  tree  by  the  inspired  air  may  pass  through  the  mucous  mem- 
brane into  the  lung  tissue  without  producing  a  visible  lesion  at  the 
point  of  entry;  pass  along  the  lymphatics  into  the  regional  lymph 
nodes  and  from  there  carried  by  the  blood  stream  into  the  pulmonary 
apices.  But  that  this  is  in  all  probabilities  rare,  may  be  assumed 
when  it  is  recalled  that  only  few  bacilli  can  reach  the  bronchi,  and  of 
these  but  few  are  allowed  to  pass  through  the  normal  mucous  mem- 
brane of  these  tubes  and  the  alveoli,  and  they  are  usually  rendered 
innocuous  by  the  protective  properties  and  functions  of  the  lymph 
and  blood,  as  was  just  shown. 

Hematogenic  Infection.— Many  look  at  phthisis  as  hematogenic  in 
origin:  The  tubercle  bacilli  are  assumed  to  enter  the  body  at  any 
point,  the  respiratory  or  digestive  tract,  or  even  through  the  skin, 
and  are  carried  by  the  blood  stream  until  they  reach  a  point  where  the 
tissues  have  a  low  power  of  resistance,  an  organ  which  offers  a  favor- 
able soil  for  the  growth  and  action  of  these  microorganisms.  Con- 
sidering the  enormous  frequency  of  pulmonary  phthisis,  it  is  evident 
that  in  the  vast  majority  of  human  beings  the  lungs  offer  a  good 
breeding-point  for  the  tubercle  bacilli.  The  localization  of  the  bacilli 
is  thus  accomplished  in  the  same  manner  as  their  localization  in  joints, 
the  peritoneum,  the  meninges,  etc. — by  the  blood  stream. 

The  hematogenic  origin  of  phthisis  is  especially  urged  by  Baum- 
garten,  Ribbert,  and  Aufrecht.     According  to  Baumgarten,  tubercle 

1  Munchen.  mediz.  Wchnschr.,  1902,  xlix,  1379. 

2  Deutsches  Arch.  f.  klin.  Med.,  1899,  Ixiv,  58. 
'  Virchows  Archiv,  1913,  ccxiii. 

^Berl.  klin.  Wchnschr.,  1909,  xlvi,  388. 


46  TUBERCULOUS  INFECTION 

bacilli  in  the  inspired  air  may  infect  the  mucous  membranes  of  the 
upper  respiratory  tract  whence  they  are  carried  by  the  lymphatics 
to  the  regional  glands — the  submaxillary,  cervical,  and  supraclavicular, 
which  are  so  often  enlarged  in  tuberculous  children.  Entering  the 
superior  vena  cava  they  may  be  carried  by  the  blood  stream  to  the 
lungs,  causing  typical  interstitial  tubercle  of  these  organs  and  finally 
extend,  while  growing,  to  the  alveolar  walls  or  within  them.  Aufrecht 
holds  that  the  primary  tuberculous  lesion  is  always  in  the  vascular 
walls,  which  are  affected  by  bacilli  brought  to  them  by  the  blood 
stream.  Through  the  veins  thej^  pass  into  the  right  heart;  or  from 
tuberculous  bronchial  glands  they  get  into  the  pulmonary  artery  or 
its  branches,  when  the  lymph  channels  are  obliterated  by  inflamma- 
tory processes,  into  the  finest  bloodvessels  and  capillaries.  Aufrecht 
has  quite  some  experimental  work  in  support  of  his  contention. 

It  is  thus  clear  that  the  aerogenic  hypothesis  of  the  origin  of  phthisis 
is  explained  by  either  a  hematogenic  or  lymphogenic  localization  of  the 
bacilli  in  the  lungs.  The  frequency  of  tuberculosis  of  the  glands, 
serous  surfaces  and  meninges  speaks  in  favor  of  such  origin  of  lung 
disease.  The  recent  discoveries  to  the  effect  that  a  bacteremia  is 
very  frequent  in  phthisis  support  this  contention. 

Infection  by  Ingestion. — The  most  important  mode  of  hematogenic 
infection  in  phthisis  should  be  the  ingestion  of  tubercle  bacilli,  although 
it  by  no  means  excludes  the  air  passages  as  portals  of  entry,  because 
germs  inhaled  through  the  mouth,  nose,  and  throat  may  be  swallowed 
and  pass  into  the  blood  through  the  mucous  membranes  at  any  point 
of  the  gastro-intestinal  tract.  However,  in  the  vast  majority  of  cases 
it  would  be  with  food,  especially  with  milk  from  tuberculous  cows, 
that  the  bacilli  would  enter  the  body  and  cause  disease. 

Simple  as  this  theory  appears,  there  are  many  objections  to  be 
considered  before  accepting  it.  The  assertions  of  some  authors  that 
tubercle  bacilli  are  invariably  killed  by  the  gastro-intestinal  juices 
has  been  found  largely  incorrect,  as  was  pointed  out  by  Romer.  To 
be  sure,  the  gastro-intestinal  juices  may,  and  usually  do,  interfere 
with  their  rapid  proliferation,  and  so  may  any  fermentation  in  the 
intestinal  tract,  while  the  peristaltic  movements  of  the  intestines  may 
soon  remove  them  from  the  body;  but  they  are  not  necessarily  killed. 
Moreover,  while  a  healthy,  unbroken  mucous  membrane  of  the  digest- 
ive tract  is  impermeable  to  tubercle  bacilli,  it  is  clear  that  a  perfectly 
normal  mucous  membrane  is  very  rare  considering  the  different  kinds 
of  food  and  its  debris  which  pass  through  it,  and  the  least  disturbance 
in  its  anatomical  structure  or  function  may  be  sufficient  to  permit 
the  passage  of  bacteria  through  its  walls. 

Experimental  investigations  have  shown  that  feeding  guinea-pigs, 
rabbits,  and  monkeys  with  tuberculous  sputum,  or  with  pure  cultures 
of  tubercle  bacilli  is  effective  in  infecting  the  animal.  INToreover,  it 
has  been  found  that  the  bacilli  may  pass  through  the  intestinal  walls 
into  the  blood  or  lymphatics  without  leaving  any  trace  on  the  walls 


INFECTION  BY  INGESTION  47 

of  the  canal.  In  some  experiments  it  was  found  that  a  couple  of  hours 
after  the  ingestion  the  bacilli  were  already  in  the  chyle. 

Because  of  this  possibility  of  the  tubercle  bacilli  entering  the  blood 
or  lymph  stream  from  the  digestive  tract,  various  authors  have  sug- 
gested the  different  parts  of  the  canal  from  the  mouth  to  the  rectum 
as  portals  or  entry  of  the  bacilli,  which  are  taken  up  by  the  blood  and 
carried  to  the  lungs  where  they  finally  stay  and  cause  phthisis.  Some 
have  stated  that  irritated  gums  during  dentition  of  infants  offer  a 
good  portal  of  entry  for  the  bacilli;  the  frequency  of  enlarged  cervical 
glands  at  that  period  of  life  was  cited  as  a  good  proof  of  the  theory. 
Others  have  accused  the  tonsils,  especially  the  pharyngeal  tonsil. 
From  the  regional  cervical  glands  some  authors  have  traced  the  bacilli 
to  the  bronchial  glands  and  finally  to  the  lungs,  though  this  has  been 
shown  by  Wood"^  and  Beitzke^  not  feasible  for  anatomical  reasons. 
However,  it  must  be  acknowledged  that  even  if  there  is  no  anatomical 
connection  favoring  the  migration  of  bacilli  from  the  cervical  glands 
to  the  lungs,  the  microorganisms  may  be  carried  to  any  place  by  the 
blood.  On  the  other  hand,  it  must  be  mentioned  that  the  tracheo- 
bronchial glands  may  be  infected  directly  from  the  lungs  by  bacilli 
which  have  reached  them  with  the  inspired  air. 

The  most  conclusive  proof  of  the  tubercle  bacilli  entering  the  lungs 
via  the  digestive  tract  has  been  brought  forward  by  Calmette  and  his 
school,  also  by  Ravenel,  Whitla,  and  many  others.  Calmette^  denies 
dust  containing  tubercle  bacilli  as  a  strong  factor  in  phthisiogenesis. 
He  could  not  produce  anthracosis  in  animals  after  subjecting  them 
to  prolonged  inhalation  of  air  saturated  with  lampblack.  Introducing 
dry  or  moist  tubercle  bacilli  directly  into  the  trachea  by  inhalation 
or  insufflation,  or  even  by  inoculation,  they  were  never  found  to  reach 
farther  than  the  bifurcation  of  the  trachea.  Introducing  lampblack 
into  the  stomach  through  a  tube,  thus  excluding  inhalation,  or  mixing 
it  with  food,  anthracosis  was  soon  produced  in  the  lungs  of  the  animals. 
Similarly,  tubercle  bacilli  introduced  carefully  into  the  stomach 
through  a  tube  with  a  view  of  preventing  aspiration  into  the  trachea, 
invariably  produced  tuberculosis.  Ravenel,^  Schlossmann,  and  St.  Engel 
could  recover  tubercle  bacilli  from  the  lungs  within  a  few  hours  after 
placing  them  in  the  stomach  by  celiotomy. 

Sir  William  Whitla's^  experiments  along  these  lines  are  very  in- 
structive. He  injected  a  mixture  of  China  ink  and  water  into  the 
large  vein  in  the  ear  of  a  rabbit.  The  animal  was  killed  an  hour  later 
and  its  lungs  were  found  highly  charged  with  carbon  particles.  He 
fed  for  four  days  a  guinea-pig  with  an  emulsion  made  by  rubbing  up 
finely  powdered  China  ink  in  olive  oil  and  water.    The  lung  was  found 

1  Ann.  Rep.  Henry  Phipps  Inst.,  190G,  iv,  1G3. 

2  Virchows  Archiv,  1906,  clxxxiv,  1. 

3  Ann.  de  I'inst.  Pasteur,  1905,  xix,  601;    1906,  xx,  ;i.53. 
••Cleveland  Med.  Jour.,  1909,  viii,  179. 

5  Lancet,  190S,  ii,  135. 


48  TUBERCULOUS  INFECTION 

blackened  by  disseminated  particles  of  carbon  in  the  upper  and  along 
the  margins  of  the  lower  lobes  within  from  eight  to  twenty-four  hours 
after  a  single  dose.  Whitla  thus  explains  the  migration  oiF  the  carbon 
from  the  gastro-intestinal  tract  to  the  lungs:  The  carbon  particles 
effect  an  easy  entrance  through  the  intestinal  epithelial  surface ;  reach- 
ing the  lacteal  or  lymphatic  paths  they  pass  through  the  lymphatic 
glands  of  the  mesentery,  and  finally,  either  inclosed  in  phagocytes  or 
free,  find  their  way  into  the  thoracic  duct  to  be  poured  into  the  venous 
circulation  before  being  arrested  in  the  capillaries  of  the  lungs.  Vas- 
steenburgh  and  Grysez's  experiments  have  also  shown  that  it  is  easy 
to  render  an  adult  guinea-pig  perfectly  anthracotic  without  subjecting 
it  to  repeated  inhalations  of  carbon  particles. 

Considerable  work  along  these  lines  has  been  done  in  this  country. 
Schroeder  and  Cotton^  found  that  no  matter  in  what  part  of  the 
body  tubercle  bacilli  are  inoculated,  pulmonary  disease  may  result. 
Charles  V.  Chapin,^  reviewing  the  literature  on  the  subject  saj^s  that 
"the  unprejudiced  reader  must  conclude  that  infection  in  either  way 
is  possible  (inhalation  and  ingestion),  but  the  conditions  of  the  experi- 
ments are  so  far  removed  from  the  natural  that  there  must  be  much 
hesitation  before  assuming  that  this  work  indicates  in  any  degree 
the  common  mode  of  infection  in  human  beings." 

From  these  and  many  other  experiments  we  are  safe  in  concluding 
that  tuberculous  infection,  including  phthisis,  may  be  acquired  through 
the  ingestion  of  tubercle  bacilli,  and  that  the  digestive  tract  permits 
the  passage  of  the  bacilli,  which  are  carried  by  the  blood  and  lymph 
streams  to  the  various  points  of  least  resistance,  of  which,  in  the  human 
being,  the  pulmonary  apices  appear  to  be  the  most  vulnerable. 

We  must  not,  however,  overlook  the  fact  which  has  been  estab- 
lished experimentally,  that  large  numbers  of  bacilli  are  necessary  to 
accomplish  results  and  the  normal  gastro-intestinal  tract  can  easily 
dispose  of  small  doses  of  tubercle  bacilli. 

Ingestion  of  tubercle  bacilli  may  result  in  tuberculosis  of  the  cervical 
or  mesenteric  glands,  depending  on  the  point  at  which  the  bacilli 
enter  the  upper  or  lower  parts  of  the  canal.  From  these  glands  the 
bacilli  are  taken  up  by  the  circulating  blood  and  carried  to  the  tracheo- 
bronchial or  mesenteric  glands  and  to  the  lungs.  In  many  cases  the 
bacilli  remain  dormant  in  these  glands  indefinitely,  causing  no  disease 
at  all;  in  others  the  latency  lasts  only  for  some  time,  when  finally, 
because  of  some  exciting  cause,  they  flare  up  again,  migrate  with  the 
blood  stream  and,  localizing  in  the  lung,  cause  phthisis,  and  we  then 
think  that  we  are  dealing  with  a  new  infection. 

Autopsies  made  by  Gaffky,^  Ungermann,  Wollstein  and  Bartlett,'' 
Ghon,-^  Hamburger,^  and  others  have  shown  that  in  children  both 

1  Rep.  Bur.  Anim.  Industry,  1906,  xxiii,  31. 

2  The  Sources  and  Modes  of  Infcetion,  Now  York,  1912,  p.  .301. 

3  Tuberkulosis,  1907,  vi,  4.37.  ••  Amer.  Jour.  Child.  Dis.,  1914,  viii,  302. 
^  Der  primiire  Lungenherd  bei  dcr  Tuberkulose  der  Kinder,  Berlin,  1912. 

*  Die  Tuberkulose  des  Kindesalter,  Vienna,  1912. 


SIGNIFICANCE  OF  BOVINE  INFECTION  .  49 

glandular  systems — the  abdominal  and  the  thoracic — are  affected 
in  nearly  the  same  proportion.  Primary  infection  of  the  intestine  is 
very  rare  in  adults,  though  in  children  it  is  quite  common.  Behring, 
however,  believes  that  all  infections  date  back  to  early  infancy  when 
the  bacilli  were  ingested,  remained  latent  to  flare  up  again  in  later 
years,  causing  disease  of  the  lungs  (see  Chapter  V).  Of  course  while 
making  autopsies  on  adults  who  died  from  chronic  tuberculosis  it  is 
difficult  or  impossible  to  find  the  point  of  primary  inoculation.  But 
in  infants  and  children  this  may  be  done  in  most  cases.  Perhaps  one 
of  the  best  criteria  is  that  in  primary  intestinal  infection  the  mesen- 
teric glands  are  implicated  while  the  intestinal  mucous  membrane 
may  remain  intact,  and  in  secondary  intestinal  tuberculosis — the 
ulcerations  so  frequently  found  in  phthisical  subjects — the  mesenteric 
glands  are  only  rarely  affected.  Statistics  of  primary  tuberculosis  of 
the  intestine  in  children  are  not  in  accord.  From  the  data  published 
by  Orth,  Eden,  Councilman,  Mallory  and  Pearce,  Lubarsch,  Wollstein 
and  Bartlett  and  many  others,  it  appears  that  the  percentage  ranges 
from  five  to  fifty.  A  large  proportion  of  these  infections  are  due  to 
bovine  bacilli,  as  was  already  shown  (p.  28). 

Significance  of  Bovine  Infection. — Nor  can  we  decide  upon  the 
channels  of  entry  of  the  tubercle  bacilli  by  a  study  of  the  type  of  these 
microorganisms  found  in  the  case.  We  must  bear  in  mind  that  cow's 
milk  contains  tubercle  bacilli  more  frequently  than  has  been  appreci- 
ated. The  studies  of  E.  C.  Schroeder,^  John  F.  Anderson,^  Ravenel 
and  others  have  shown  this  to  be  a  fact  in  this  country.  M.  Rosenau^ 
compiled  data  conoerning  551  samples  of  milk  examined  in  which 
tubercle  bacilli  were  found  in  46,  or  8.3  per  cent.,  and  he  says  that 
this  may  be  taken  as  the  average  percentage  for  the  entire  country. 
But  practically  all  the  cases  of  pulmonary  phthisis  are  due  to  the 
humg,n  type  of  bacilli,  and  in  countries  where  milk  is  hardly  used  as 
a  food,. as  is  the  case  in  Japan,  China,  India,  Egypt,  etc.,  phthisis  is 
not  lacking,  as  has  been  shown  by  Kitasato^  and  others.  Moreover, 
the  Imperial  Health  Department  of  Germany  has  made  a  collective 
investigation  on  the  subject  of  bovine  infection  as  a  cause  of  tuber- 
culosis of  the  lungs  and  found  that  out  of  280  children,  all  of  whom 
had  been  fed  since  infancy  on  milk  derived  from  cows  with  tuber- 
culous udders,  only  2  became  sick  with  tuberculosis  during  seven 
years,  and  not  a  single  case  of  death  occurred  among  them. 

We  have  seen  that  the  tuberculosis  in  children  caused  by  bovine 
infection  consists  almost  invariably  in  diseased  glands,  skin,  bones, 
joints  and  intestines,  and  fatal  phthisis  is  exceedingly  rare  (p.  29). 
There  is  also  ample  evidence  that  the  adult  is  practically  immune  to 
the  bovine  bacilli,  even  if  his  immunity  to  the  human  type  of  bacilli 

1  Bull.  No.  99,  Bureau  of  Animal  Industry,  1907. 

2  Jour.  Infect.  Dis.,  1908,  v,  107. 

^  Preventive  Medicine,  New  York,  1913,  p.  513. 
^  Sixth  Intern.  Congr.  on  Tuberculosis,  1908,  vi,  1. 


50  TUBERCULOUS  INFECTION 

has  not  yet  been  established  to  the  satisfaction  of  all.^  Younger 
individuals,  when  infected  with  the  bovine  type  of  bacilli  find  it  more 
or  less  easy  to  cope  with  the  situation  and  to  recover,  even  if  they  finally 
emerge  with  disfigurement,  or  perhaps  crippled.  But  if  the  problem 
of  tuberculosis  was  only  that  part  which  is  produced  by  the  bovine 
bacilli,  it  would  not  have  by  far  the  significance  it  has  at  present, 
fa  fact  several  authors,  especially  Riviere,^  are  of  the  opinion  that 
these  mild  bovine  infections  immunize  the  organisms  against  infection 
with  the  more  virulent  human  type,  as  will  be  discussed  later  on. 

Evaluation  of  Experimental  Data. — On  the  whole  the  experimental 
evidence,  though  ample  in  quantity,  is  not  always  in  agreement  with 
what  would  be  expected  a  priori;  nor  are  the  results  of  one  investiga- 
tion invariably  the  same  as  those  obtained  by  another  who  ostensibly 
followed  the  same  method. 

The  differences  in  the  results  of  experimental  investigations  are  best 
explained  by  lack  of  equilibrium  between  the  host  and  the  parasite, 
as  has  been  found  by  many  bacteriologists,  notably  Theobald  Smith,^ 
who  says:  "It  varies  with  the  species,  race,  nationality,  or  even 
family  of  the  host  and  many  other  accessory  conditions.  It  depends 
on  the  race  of  the  tubercle  bacilli.  In  experiments  such  conditions 
as  age  of  culture,  total  period  of  cultivation,  character  of  the  culture 
medium,  condition  of  aggregation  of  the  bacilli,  mode  of  application 
and  dosage  are  of  great  importance  in  determining  the  outcome  of 
the  experiment.  Similarly,  the  outcome  will  vary  according  to  the 
species  of  animal  on  which  we  are  experimenting." 

There  are  other  reasons  why  we  should  be  careful  before  applying 
experimental  finding  to  clinical  medicine.  Even  among  various  species 
of  animals  the  results  are  not  always  the  same  when  an  experiment 
has  been  performed  in  the  same  identical  manner  and  with  the  same 
culture  of  bacilli.  Thus,  as  has  been  pointed  out  by  Weber,  after 
inoculating  subcutaneously  guinea-pigs  with  bovine  bacilli  there  results 

1  Inasmuch  as  this  may  appear  to  be  a  sweeping  statement  I  will  cite  at  some  detail 
Felix  Klemperer's  experiments:  In  Feb^uarJ^  1900,  he  injected  subcutaneously  bovine 
bacilli  into  his  arm.  Ten  months  later  he  excised  the  indurated  subcutaneous  cellular 
tissue  at  the  site  of  the  injection.  Microscopic  examination  showed  well-organized 
granulation  tissue  vdth  giant  cells  but  no  caseation.  No  tubercle  bacilli  could  be  dis- 
covered, sho-n-ing  that  tuberculosis  was  probably  absent,  and  the  tissue  changes  were 
at  any  rate  not  characteristic  of  tuberculosis.  Another  physician,  who  had  been  tuber- 
culous for  fourteen  years,  also  submitted  to  similar  injections  of  bovine  baciUi.  In 
this  experiment  the  indi^-idual  was  given  fourteen  injections  without  producing  any 
results.  Four  other  tuberculous  patients  were  injected  with  tuberculous  lymphatic 
tissue  from  guinea-pigs.  A  total  number  of  thirty-nine  injections  of  bovine  bacilli 
were  administered  to  these  four  patients.  The  local  effects  were  slight.  Four  times 
abscesses  were  produced  which,  however,  healed  sooner  or  later.  General  constitutional 
effects  were  not  observed  in  any  case,  the  patients  even  stated  that  they  felt  better 
and  they  gained  in  weight  during  the  treatment.  Klempercr  concludes  that  there 
is  no  doubt  that  subcutaneous  injection  of  bovine  bacilli  is,  within  certain  limits,  harm- 
less to  the  tuberculous  individual  (Zeitschr.  f.  klin.  Med.,  1905,  Ivi,  2-11).  Baum- 
garten  performed  similar  experiments  on  cancerous  patients  with  the  same  results. 

2  British  Journal  of  Tul^erculosis,  1914,  viii,  83. 

3  Harvey  Lectures,  1905-1906,  p.  273. 


CONCLUSIONS  51 

disease  first  of  the  spleen,  and  second  of  the  Hver,  but  the  kidneys  are 
almost  never  affected,  while  in  the  rabbit  the  kidneys  are  affected 
next  to  the  lungs.  The  lung  of  the  hen  is  practically  refractory  to  the 
typus  gallinaceous  of  the  acid-fast  bacilli.  In  the  rabbit  there  is 
always  an  infection  of  the  lymph  glands  after  inoculation  of  bovine 
bacilli,  but  when  human  bacilli  are  inoculated  these  glands  are  never 
affected.  Inasmuch  as  the  internal  organs  are  affected  after  subcutane- 
ous inoculation,  it  is  evident  that  the  bacilli  pass  the  regional  lymph 
glands  without  harming  them.  Rats  respond  to  infection  with  the 
human  type  of  bacilli  in  the  same  way  as  rabbits.  There  is  no  doubt 
that  various  strains  of  the  same  type  of  bacillus  produce  different 
results  when  inoculated  into  the  same  species  of  animals,  and  in 
humans  the  different  types  of  disease  resulting  from  infection  may 
undoubtedly  be  attributed  to  the  same  causes.  Chronic  phthisis  is 
a  distinctly  human  disease  which  never  occurs  in  animals  sponta- 
neously, nor  has  it  ever  been  induced  experimentally. 

Conclusions. — A  survey  of  the  evidence  presented  in  this  chapter 
shows  clearly  that  there  is  no  agreement  among  authorities  as  to  the 
most  common  channel  of  entry  of  the  tubercle  bacilli  before  causing 
phthisis.  The  reason  is  clear  when  we  bear  in  mind  that  experimental 
investigations  in  laboratories  have  in  most  cases  not  duplicated  natural 
conditions  among  human  beings.  Charles  V.  Chapin,  who  has  so 
well  pointed  out  this  fact,  arrives  at  the  conclusion  that  it  is  highly 
desirable  that  a  sufficient  number  of  well-conducted  experiments 
under  truly  natural  conditions  be  made  to  determine  the  relative 
importance  of  inhalation  of  dessicated  sputum,  and  the  ingestion  of 
the  bacilli  in  the  spread  of  the  disease.  Romer,  perhaps  the  most 
indefatigable  experimental  worker  in  the  field  of  tuberculosis,  also 
says  that  there  is  evidently  some  mode  of  transmission  of  this  disease 
with  which  we  are  as  yet  unacquainted. 

It  must,  however,  be  mentioned  here,  a  point  which  will  be  dis- 
cussed in  detail  later  on,  that  infection  alone  is  not  sufficient  to  produce 
phthisis;  the  disease  occurs  after  all  in  only  a  certain  proportion 
of  persons  infected  with  the  tubercle  bacilli.  In  other  words,  while 
there  is  no  phthisis  without  tubercle  bacilli,  these  microorganisms  can 
only  harm  one  who  is  predisposed  to  the  disease.  Under  the  circum- 
stances phthisiogenesis  is  more  a  problem  of  predisposition  than 
of  infection. 


CHAPTER  III. 

THE  EPIDEMIOLOGY  OF  TUBERCULOSIS. 

Ubiquity  of  the  Tubercle  Bacillus. — In  our  survey  of  the  biological 
characteristics  and  the  channels  of  entry  of  the  tubercle  bacilli  we  found 
that  the  virus  of  tuberculosis  is  ubiquitous;  that  it  is  found  where- 
ever  civilized  human  beings  congregate,  because  tuberculous  human 
beings  expectorate  sputum  containing  these  bacilli,  and  domestic 
animals  affected  with  this  disease  are  everywhere.  It  has  been 
estimated  that  the  number  of  bacilli  discharged  daily  in  the  sputum 
of  a  single  patient  with  advanced  phthisis  is  as  great  as  the  number  of 
human  beings  on  the  earth.  The  modest  estimate  mentioned  by 
Cornet  may  be  taken  as  near  the  truth— that  7,200,000,000  bacilli 
may  be  thrown  off  daily  from  a  single  patient.  If  we  imagine  each 
organism  placed  end  to  end  in  a  single  file,  this  number  would  con- 
stitute a  chain  no  less  than  twelve  miles  in  length. 

Clinical  and  experimental  medicine  have  shown  conclusively  that 
the  expectoration  of  consumptives,  milk  from  tuberculous  animals, 
etc.,  are  capable  of  causing  infection;  that  these  microorganisms  may 
enter  the  body  through  wounds,  as  well  as  through  the  unbroken 
skin,  and  the  mucous  surfaces  of  the  respiratory  and  alimentary  tracts, 
etc.  We  have  also  shown  that  though  there  are  many  hindrances 
in  the  way  of  infection,  still  when  everything  stated  in  the  last  chapter 
is  considered,  it  is  not  surprising  that  one  out  of  eight  in  civilized 
countries  succumbs  to  the  disease,  but  that  the  other  seven  escape 
its  ravages. 

Tuberculous  Infection  vs.  Tuberculous  Disease. — As  a  matter  of 
fact  very  few  escape  infection  with  the  tubercle  Ijacilli,  especially 
of  those  living  in  large  industrial  cities.  When  we  make  this  statement 
we  want  to  emphasize  that  a  distinction  is  to  be  made  l^etween  tuber- 
culous infection  and  tuberculous  disease.  The  latter  refers  to  the 
disease  known  for  centuries,  ever  since  Hippocrates  described  it, 
as  consumption  or  the  equivalent  of  the  term  found  in  all  European 
languages.  It  is  the  disease  which  causes  more  than  95  per  cent,  of 
the  suffering,  social  and  economic  misery  and  deaths  due  to  the  tubercle 
bacilli.  On  the  other  hand,  tuberculous  infection  covers  all  the  cases 
in  which  the  virus  of  tuberculosis  has  entered  the  body,  irrespective 
whether  it  has  caused  disease  or  not.  Tubercuk)us  disease  is  always 
preceded  by  infection,  but  infection  with  the  tubercle  bacilli  is  not 
invariably  followed  by  disease. 

Research  of  the  past  three  decades  has  shown  conclusively  that 


FREQUENCY  OF   TUBERCULOUS  INFECTION  53 

infection  with  tubercle  bacilli  is  not  invariably  followed  by  that  train 
of  symptoms  which  we  observe  in  phthisis;  that  it  does  not  necessarily 
cause  any  sickness,  excepting  an  altered  reactivity  to  tuberculin. 
Apparenth'  more  people  harbor  the  bacilli  within  their  bodies,  or  show 
traces  of  having  harbored  them,  without  knowing  it  at  all,  than  such 
as  suffer  or  succumb  as  a  result  of  tuberculosis  of  the  lungs  or  other 
organs.  These  persons  are  undoubtedly  tuberculous,  and  there  are 
many  strong  reasons  that,  like  other  bacillus  "carriers,"  they  are 
liable  to  cause  mild  infection  with  tuberculosis.  But  they  are  not  at 
all  phthisical  in  the  clinical  sense.  Some  of  them  are  destined  to 
become  phthisical;  in  fact  practically  all  phthisis  evolves  from  an 
infection  acquired  during  childhood,  as  w^e  shall  show  when  discussing 
phthisiogenesis. 

Frequency  of  Tuberculous  Infection. — Careful  and  painstaking 
scientific  investigations  have  showai  that  the  frequency  of  tuberculous 
infection  goes  hand  in  hand  with  civilization,  or  contact  of  primitive 
peoples  with  civilized  humanity.  In  modern  large  cities  very  few 
persons  escape  infection.  Autopsies  made  with  a  view  of  ascertaining 
traces  of  tuberculous  lesions,  both  active  and  healed,  have  shown  that 
over  90  per  cent,  of  adults  are  thus  affected  among  the  civilized; 
but  among  primitive  peoples  no  tuberculous  changes  are  found  at 
autopsies. 

In  Laennec's^  classical  work  on  diseases  of  the  lungs  published  in 
1831  we  find  the  following  in  a  footnote:  "M.  Lombard's  investiga- 
tions in  the  Children's  Hospital  at  Paris  show  that  of  the  children  who 
die  between  one  and  two  years  of  age,  one-eighth  are  tuberculous; 
between  two  and  three,  two-sevenths;  between  three  and  four,  four- 
sevenths;  between  four  and  five,  three-fourths.  In  the  succeeding 
years  up  to  puberty,  tubercles  are  found  more  frequently  than  before 
the  fourth,  but  much  less  frequently  than  from  the  fourth  to  the 
fifth.  Papavoine,  of  the  same  hospital,  found  that  the  number  of 
tuberculous  children  between  the  fourth  and  eleventh  years  is  greater 
than  those  who  are  not  tuberculous,  tubercles  being  particularly 
prevalent  from  the  fourth  to  the  seventh  years.  Their  frequency  is 
again  increased  about  the  twelfth  and  thirteenth  years,  and  at  four- 
teen and  fifteen  years  the  rate  of  prevalence  is  the  same  as  at  four 
and  five.  These  results  were  obtained  from  investigations  made  on 
910  children  (388  boys  and  522  girls);  somewhat  less  than  three-fifths 
were  tuberculous." 

Similarly,  Henry  AncelP  emphasized  the  extent  of  tuberculous  disease 
in  London  as  far  back  as  1840.  In  a  paper  on  "Facts  and  Opinions 
Relating  to  Tuberculosis,  with  Commentaries,"  he  cites  the  Decenium 
Pathologicmn  of  Dr.  L.  K.  Chambers,  giving  the  results  of  the  post- 
mortem examinations  made  in  the  mortuary  of  St.  George's  Hospital 

1  Traite  de  I'aiiscultation  mediate  et  des  maladies  des  poumons  et  du  cceur,  Paris, 
1S31,  ii,  125. 

2  Association  Med.  Journal,  1853,  p.  1030;  quoted  from  Karl  Fearson,  loc.  cit.,  p.  19. 


54  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

in  the  ten  years,  December  31,  1840,  to  December  31,  1850.     The 
number  of  autopsies  was  2046.    The  following  are  the  figures: 


Birth  to 
15  years. 

15  to  30. 

30  to  45. 

45  to  GO. 

Above 
60. 

All. 

154 

29.7 

636 
35.8 

651 

25.8 

438 
19.6 

167 

7.7 

2046 
26.1 

Total  number  of  autopsies 
Per  cent,  of  tubercle  found 

It  appears  that  these  facts  were  entirely  forgotten,  and  medical 
literature  was  silent  about  the  extent  of  tuberculous  infection  and 
changes  in  the  bodies  of  many  who  have  shown  no  indication  of  disease 
during  life,  until  in  1900  Naegeli^  published  his  report  of  500  autopsies 
at  the  Pathological  Institute  at  Zurich.  He  found  71  per  cent,  showed 
pathological  changes  due  to  tuberculosis.  Among  individuals  under 
eighteen  years  of  age,  only  25  per  cent,  showed  such  lesions,  mostly 
of  a  grave  character,  often  leading  to  a  fatal  termination.  But  in 
persons  above  eighteen  years  of  age  the  proportion  that  showed  traces 
of  tuberculous  infection  reached  98  per  cent.  Of  these  only  28  per  cent, 
died  as  a  result  of  this  disease,  while  the  rest  had  tuberculous  foci 
which  were  either  altogether  healed,  quiescent,  or  slowly  progressing. 

When  first  published  this  revelation  appeared  incredible,  but 
when  other  pathologists  investigated  autopsy  material  along  the  same 
lines,  they  practically  confirmed  Naegeli's  findings.  From  the  works 
of  Harbitz,  Scheel,  Burckhardt,  Lubarsch,  Adami^  and  McCrea,  and 
many  others,  it  was  clear  that  very  few  persons  escape  infection  with 
tubercle  bacilli  before  reaching  the  age  of  maturity.  They  have  all 
found  that  no  matter  what  the  cause  of  death  may  have  been,  whether 
the  persons  knew  that  they  had  been  tuberculous  .or  not,  between 
50  and  100  per  cent,  of  people  living  in  large  cities  show  active,  quies- 
cent or  healed  tuberculous  lesions  in  some  organs  of  their  bodies. 
On  this  point  all  are  now  in  agreement,  the  only  dispute  which  may  be 
found  in  the  literature  consists  in  whether  the  percentage  is  only 
70,  or  reaches  as  high  as  100.  Thus,  Lubarsch^  states  that  Naegeli 
has  exaggerated  his  findings,  because  of  7371  necropsies  performed  by 
Naegeli,  Burckhardt,  Risel  and  Lubarsch,  only  4230,  or  57.4  per  cent., 
showed  tuberculous  changes;  of  5796  necropsies  on  adults,  4017,  or 
69.2  per  cent.,  showed  such  changes. 

These  autopsies  showed  another  significant  fact:  The  newborn 
infant  is  invariably  free  from  tuberculosis,  indicating  that  infection, 
if  it  occurs  at  all,  always  takes  place  after  birth.  Among  infants 
dying  during  the  first  year  of  life  from  any  cause,  some  are  found 
presenting  lesions  of  a  tuberculous  character,  while  beginning  with 
the  second  year  the  number  of  infected  children  increases  steadily, 
so  that  at  the  age  of  fifteen  there  are  nearly  as  many  tuberculous 
among  them  as  among  adults.     In  this  country  Martha  Wollstein 

1  Virchows  Archiv,  1900,  clx,  426. 

2  Trans.  Sixth  Internat.  Congr.  on  Tuberculosis,  1908,  i,  325. 
^  Virchows  Archiv,  1913,  ccxiii,  417. 


FREQUENCY  OF  TUBERCULOUS  INFECTION  55 

and  F.  H.  Bartlett^  reported  1320  autopsies  performed  at  the  Babies' 
Hospital  in  New  York  City  on  children  under  five  years  of  age,  of 
which  118,  or  13.5  per  cent.,  showed  tubercuk)us  changes.  In  Europe 
the  proportion  is  even  higher,  as  is  evident  from  the  finding  of  Naegeh, 
Burckhardt,  Lubarsch,  Hamburger,  and  many  others. 

The  most  recent  series  of  autopsies  on  children  has  been  reported 
by  Harbitz.^  In  the  Anatomical  Institute  at  Christiania,  Sweden, 
during  1898  to  1911,  the  bodies  of  484  children  who  died  from  any 
cause  were  dissected.  The  ages  ranged  from  birth  to  fifteen  years. 
His  results  are  given  in  the  following  figures: 

Number  Tuberculous  lesions. 

Age.  examined.  Per  cent. 

0  to     1  year 201  20.0 

1  to    2  years 65  26 . 2 

3  to    4       " 44  31.8 

5  to    6      " 28  '         67 . 9 

7  to  10      " 53  62.2 

11  to  14      " 53  81.1 

15      " 40  80.0 

Total 484  41.08 

The  anatomical  picture  was  predominantly  that  of  tuberculosis 
of  the  lungs  and  the  lymphatic  glands,  especially  those  of  the  thorax. 
The  younger  the  child,  the  more  acute  and  progressive  the  lesion  found. 
In  only  one  case  could  he  suspect  congenital  tuberculosis. 

Another  point  has  been  brought  out  by  these  autopsies  which 
is  of  immense  epidemiological  and  clinical  importance.  The  tuber- 
culous lesions  found  at  the  autopsies  are  not  all  active,  nor  were 
they  the  cause  of  death  in  many  cases.  Indeed,  there  were  many  which 
were  latent,  quiescent,  or  even  healed.  Thus  among  the  406  tuber- 
culous bodies  examined  by  Naegeli,  28.1  per  cent,  had  healed  or 
latent  lesions;  among  Burckhardt's  1452  autopsies  he  found  1221, 
or  84.1  per  cent.,  tuberculous;  but  39.4  per  cent,  of  them  showed 
quiescent,  latent  or  healed  lesions.  The  results  of  nearly  all  other 
investigations  show  the  same  conditions. 

Active  and  progressive  lesions,  leading  to  death,  are  characteristic 
of  infancy;  in  fact,  during  the  first  year  of  life  all  lesions  discovered 
at  autopsies  are  those  of  a  generalized  and  progressive  tuberculosis. 
Localized  lesions  are  rare  in  childhood,  and  only  make  their  appearance 
after  the  second  year,  but  are  still  rare  at  ten  years  of  age.  Lubarsch 
has  analyzed  his  findings  from  this  viewpoint  and  arrives  at  the 
conclusion  that  the  younger  the  individual  infected  with  tuberculosis, 
the  more  likely  he  is  to  be  killed  by  the  disease,  while  the  older  the 
individual,  the  less  is  he  likely  to  suffer  from  acute  and  progressive 
disease.  In  fact,  he  says  that  among  older  persons  tuberculosis  is 
a  relatively  harmless  process,  showing  as  it  does  a  strong  tendency 

1  Arner.  Jour.  Dis.  Child.,  1914,  viii,  364. 

2  Norsk  mag.  f.  Laegevidesk.,  1913,  5  R.,  xi,  1. 


56  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

to  latency  or  healing.  He  illustrates  this  point  by  the  following 
statistical  facts: 

Among  502  infants  under  one  year  examined  after  death,  4.58 
per  cent,  were  found  with  tuberculous  lesions  all  of  which  were  acute 
or  subacute  general  tuberculosis,  without  any  tendency  to  localization 
in  a  single  organ.  Of  123  children  two  years  of  age,  20.3  per  cent, 
were  found  with  tuberculous  lesions.  All  were  also  active  and  pro- 
gressive, though  there  were  already  seen  tendencies  to  localization 
of  the  process,  but  no  calcification  was  noted.  At  three  years  of  age 
24.7  per  cent,  of  the  bodies  showed  tuberculous  changes,  and  in  one 
some  evidences  of  calcification  were  found  microscopically  in  a  tuber- 
culous bronchial  gland.  He  found  that  the  number  of  active  and 
fatal  cases  of  tuberculosis  keeps  up  at  a  high  level  till  the  age  of  fifteen, 
when  localized  tuberculosis  begins  to  manifest  itself,  though  the 
lesions  still  show  tendencies  to  progression,  and  calcification  is  still 
exceptional.  Thus,  among  139  tuberculous  bodies  of  individuals 
between  one  and  sixteen  years  of  age,  only  33,  or  23.7  per  cent,  showed 
calcified  foci,  but  none  were  completely  healed — all  were  active  and 
progressive  in  character. 

Only  after  the  seventeenth  year  of  life  are  to  be  noted  latent  and 
healed  tuberculous  lesions  at  autopsies,  and  they  keep  on  increasing 
in  frequency,  so  that  at  the  age  of  forty  they  are  more  frequent  than 
progressive  lesions.  The  following  table,  as  well  as  Fig.  1,  shows  the 
point  clearly: 

Latent  and 
Active  lesions.  healed  lesions. 

Age.  Per  cent.  Per  cent. 

17  to  20 77.4  22.6 

20  to  30 76.7  23.3 

30  to  40 52.6  47.4 

40  to  50 38.9  61.1 

50  to  60 33 . 5  66 . 5 

60  to  70 23 . 3  76 . 7 

70  to  80 14.7  85.3 

80  to  90 9.3  90.7 

90  to  100 0.0  100.0 

The  frightful  tuberculization  of  humanity,  as  revealed  by  these 
autopsy  findings,  was  explained  by  some  authors  as  due  to  the  fact 
that  in  hospitals  there  is  a  concentration  of  tuberculous  sick,  and  among 
children  who  succumb  at  an  early  age,  the  percentage  of  tuberculous 
should  be  much  higher  than  among  those  who  survive  till  maturit}^ 
But  it  must  be  recalled  that  these  autopsy  findings  were  obtained  in 
children  who  died  from  all  causes,  and  that  in  many  the  tuberculous 
lesions  were  found  incidentally,  although  the  causes  of  death  were 
entirely  different  diseases. 

Many  objections  have  been  raised  against  these  autopsy  statistics 
showing  that  nearly  all  adults  living  in  cities  harbor  tuberculous  lesions 
in  their  bodies.  Some  have  maintained  that  many  non-tuberculous 
changes  in  the  lungs  and  pleura-have  been  included  as  latent  or  healed 


FREQUENCY  OF  TUBERCULOUS  INFECTION 


57 


XNao  aad 


58  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

tuberculosis.  But  Naegeli,  Burkhardt  and  others  have  pointed  out 
that  pleuritic  scars  and  adhesions  with  underlying  pulmonary  indura- 
tions were  considered  remnants  of  tuberculosis  only  when  there  were, 
in  addition,  found  calcified  or  caseated  foci  in  the  lungs  or  lymph 
glands,  or  when  tubercle  bacilli  were  found  microscopically.  It  has 
also  been  stated  by  Cornet  that  these  latent  lesions  were  caused  by 
avirulent  or  mildly  virulent  tubercle  bacilli,  perhaps  even  by  non- 
pathogenic acid-fast  microorganisms.    But  this  has  not  been  proved. 

The  objection  has  also  been  raised  that  the  autopsy  material 
obtained  in  morgues  in  large  cities  represents  the  lowest  grades  of 
society,  the  poorest  strata  of  population,  who  are  most  likely  to  suc- 
cumb to  tuberculosis,  while  the  well-to-do  or  self-supporting  elements 
of  society,  even  in  cities,  are  by  no  means  tuberculous  to  such  an 
appalling  extent.  But  it  is  the  poor  who  present  the  problem  of  tuber- 
culosis most  acutely.  Naegeli  also  pointed  out  that  his  material  was 
not  exclusively  of  the  lowest  strata  of  society.  Forty  per  cent,  at 
least  were  country  folk,  and  6.5  per  cent,  were  private  patients. 
Moreover,  only  in  22.5  per  cent,  was  tuberculosis  the  cause  of  death, 
as  against  28  per  cent,  occurring  among  the  general  population  of  the 
Canton  of  Zurich,  thus  showing  that  the  persons  on  whom  he  made 
his  autopsies  were  not  excessively  tuberculized.  In  fact,  large  series 
of  autopsies  made  in  many  other  cities  confirmed  Naegeli's  findings. 

Better  confirmation  of  these  findings  was,  however,  supplied  by 
several  series  of  autopsies  made  on  persons  who  have  enjoyed  good 
health  but  succumbed  to  accidents  or  acute  diseases.  Among  826 
autopsies  made  on  such  individuals,  Birch-Hirschfeld^  found  171,  or 
20.7  per  cent.,  with  tuberculous  lesions.  Of  these  105,  or  12.7  per  cent., 
were  healed  lesions;  31,  or  3.8  per  cent.,  were  actively  advanced;  35, 
or  4.2  per  cent.,  were  latent  or  mildly  active.  Similar  results  were 
recently  reported  by  J.  G.  Monckenberg^  who  made  autopsies  on  85 
soldiers,  fallen  in  the  European  War.  In  25,  or  31.76  per  cent.,  he 
found  distinct  evidences  of  active,  latent,  or  healed  tuberculosis.  In 
5  cases  the  lesions  were  so  active  that  they  may  have  been  the  cause 
of  death,  but  in  the  remaining  22  cases  the  tuberculous  lesions  were 
incidental  findings. 

Extent  of  Tuberculous  Infection  among  the  Living. — The  extent  of 
tuberculous  infection  among  the  living  population  has  been  ascertained 
by  the  application  of  the  tuberculin  test  which  is  even  more  delicate 
than  the  macroscopic  examination  of  the  body  after  death,  showing, 
as  it  does,  the  number  of  persons  infected  with  tubercle  bacilli  and 
who  have  survived  or  have  not  at  all  suffered  as  a  result  of  the  infection. 
No  matter  how  slight  the  lesion  produced  by  the  tubercle  bacilli, 
the  tuberculin  test  reveals  it. 

Extensive  investigations  have  been  made  along  these  lines,  and  it 
was  found  that  there  are  very  few  adults  living  in  cities  who  do  not 

1  Deutsches  Archiv  f.  klin.  Medizin,  1899,  Ixiv,  58. 

2  Zeitschr.  f.  Tuberculose,  1915,  xxiv,  33. 


TUBERCULOUS  INFECTION  AMONG   THE  LIVING 


59 


react  to  tuberculin.  Those  who  Hve  in  tubercle-laden  surroundings 
hardly  ever  escape  infection.  Pollak^  found  that  in  Vienna  96  per 
cent,  of  children  of  tuberculous  parentage  were  infected  before  they 
reached  the  fourth  year  of  life;  Mantoux^  found  that  84  per  cent, 
were  infected  before  they  reached  the  fifteenth  year;  in  New  York 
City  the  author^  has  found  that  children  living  with  their  tuberculous 
parents  are  infected  to  the  extent  of  84  per  cent,  at  the  age  of  fourteen, 
as  can  be  seen  from  the  table  and  the  attached  diagram  (Fig.  2). 
Similar  results  have  been  obtained  while  testing  large  numbers  of 
children  of  tuberculous  parentage  in  various  European  cities. 


100 
90 

80 


uJ  50 


40 


30 


20 


10 


AGE   6mos.  6-r2Mos.2YRs. 


^ 

....                                                                                                                                                  ^^                                                                    ^ 

'    '  '                               ''  ^^             ^  ''     n^ 

W'r~ni""i~M-  i  <f    r*""'— 4— ^ 

_  ^.  =  =  ::=:  ==_4J ^- IpSr^s, ^^^^^i I 

f. r±L^___4^i___^_____,^__--._i^-^--^                ------ 

i                                                                                         .^  "                                                                             ,       1          '       ' 

f                                                                           y'        -■   ■                                                                   ;      11.          . 

J                                      jk-                                                1       , 

I                                j^ci                                              -^u  o- 

r                                    -;     ,     ,' —         -    '                                                        ill, 

]                               ^'ZL       Tt                                                         -^ 

I                       ,•-                                                                 T 

'- 

-•' 

-  _          ^      ,             —        _ 

i         ,'                                       ^^ 

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t     -'^    

t     -.                                                                       ^  T 

''     t                                                        ^1 

I                 A                                                                                    "                                                                                                  '     •                ^            -—^-^                     '■ 

I            r                                                                                                                                                                      1                   i    :               i 

-"       ^           7"                                          "  "                                             J_                                                    _^i_          -^ 

/         .^ 

2      ? 

>         '^   ?                                       - _                       

^7 

Fig.  2. — Proportion  of  children  reacting  to  the  cutaneous  tuberculin  test.  Black 
line  represents  692  children  of  tuberculous  parentage  in  New  York  City;  dotted  line 
represents  588  children  of  non-tuberculous  parentage  in  New  York  City. 


Table  Showing  Extent  of  Tuberculous  Infection  among  the  Poorer  Classes 

IN  New  York  City  Based  on  the  Application  of  the  Tuberculin 

Test  on  1280  Children  under  Fifteen  Years  of  Age. 

Percentage  giving  positive  reactions  among 


Age. 

Under    1  year 

1  to    2  years 

3  to    4 

5  to    6 

7  to  10 

11  to  14 

14 


Children  of  tuberculous 
parents. 
Niunber   of 

cases.  Per  cent. 

33  15.15 

49  55.10 

90  68.88 

95  65 . 26 

.  244  71.31 

.  181  74.58 

37  83.79 


Children  of  non-tuberculous 

parents. 
Number  of 


cases. 

56 

39 

80 

106 

173 

134 

20 


Per  cent. 
10.07 
33.33 
41.25 
50.00 
64.74 
69.40 
75.00 


1  Brauer's  Beitrage,  1911,  xix,  469. 

2  Semaine  Medicale,  1909,  xxix,  371;  Presse  Med.,  1910,  xviii,  10. 

3  Archives  of  Pediatrics,  1914,  xxxi,  96,  197. 


60  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

Taking  apparently  healthy  children  at  random,  i.  e.,  those  who 
do  not  live  in  homes  harboring  evidently  tuberculous  persons,  it 
appears  that  they  are  also  infected  in  large  numbers.  Hamburger^ 
found  that  at  the  age  of  fourteen  94  per  cent,  of  the  children  of  artisans 
in  Vienna  show  signs  of  infection  with  tuberculosis.  Calmette-  at 
Lille,  France,  testing  1226  persons  of  all  ages  taken  at  random  from 
diverse  social  strata,  all  apparently  healthy,  found  that  during  the 
first  year  of  life  only  9  per  cent,  were  infected,  but  the  percentage 
kept  on  increasing,  so  that  at  the  age  of  fifteen  and  over,  87  per  cent, 
were  infected.  In  New  York  City  the  author^  found  while  testing 
children  of  poor,  but  non-tuberculous  parentage,  that  under  one  year 
of  age  10  per  cent,  were  infected;  between  one  and  two  years  of  age, 
33.33  per  cent.,  and  the  proportion  giving  positive  reactions  to  tuber- 
culin kept  on  growing  steadily  with  advancing  age  so  that  at  the  age 
of  fourteen  75  per  cent,  of  "reactors"  were  found. 

It  is  well  known  that  the  von  Pirquet  test,  which  was  used  in  these 
cases,  is  occasionally  negative  when  applied  the  first  time,  but  is 
positive  when  applied  a  second  or  third  time.  For  this  reason  some 
who  have  applied  the  test  but  once  found  a  lesser  number  of  reactors. 
J.  B.  Manning  and  H.  J.  Knott,*  in  Seattle,  tested  228  children,  aged 
ten  to  fourteen  years,  coming  to  the  Children's  Tuberculosis  Clinic, 
the  large  majority  of  which  were  from  tuberculous  homes.  Of  166 
with  a  definite  history  of  exposure  84,  or  50.6  per  cent.,  gave  a  positive 
von  Pirquet  test,  though  82.1  per  cent,  of  these  children  showed  no 
clinical  evidences  of  tuberculosis.  Of  62  children  with  no  history  of 
exposure  14,  or  22.8  per  cent.,  were  reactors.  But  they  used  only  one- 
half  strength  of  tuberculin,  and  when  found  negative  after  the  first 
application,  the  test  was  not  repeated.  Had  they  applied  it  twice  or 
three  times,  and  in  full  strength,  the  proportion  of  reactors  would 
undoubtedly  have  been  higher.  George  H.  Cattermole^  tested  children 
in  Boulder,  Colorado,  where  there  is  no  overcrowding,  but  plenty  of 
good  food  and  sunshine.  Probably  one-half  the  families  in  Colorado 
contain  one  or  more  adult  consumptives.  It  would  be  expected  that 
the  number  of  reactors  should  be  quite  large.  Yet  only  38  per  cent, 
were  found  to  have  been  infected.  This  anomaly  may  be  explained 
by  the  superior  social  and  economic  conditions,  but  it  seems  to  me 
that  the  following  reasons  are  more  plausible :  The  number  of  children 
was  rather  small,  only  66;  if  he  had  extended  his  investigations  the 
results  might  have  been  different;  he  applied  the  test  but  once  in 
most  cases,  using  the  von  Pirquet  and  the  Moro  tests.  At  any  rate 
it  appears  that  opportunities  for  infection  were  not  altogether 
counter-balanced  by  superior  climatic  and  economic  conditions. 

1  Die  Tuberkulose  im  Kindesalter,  Berlin,  1913. 

'  Grysez  et  Letulle,  Presse  Medicale,  1911,  xix,  651. 

3  Archives  of  Pediatrics,  1915,  xxxii,  20. 

■■  Amer.  Journ.  Dis.  of  Children,  1915,  x,  354. 

5  Jour,  Amer.  Med.  Assn.,  1915,  Ixv,  782. 


TUBERCULOSIS  AMONG  PRIMITIVE  PEOPLES  AND  RACES      61 

While  it  is  in  large  industrial  cities  that  tuberculosis  is  most  wide- 
spread, as  is  shown  by  the  high  morbidity  and  mortality  from  the 
disease,  infection  is  not  lackiaig  in  rural  communities  of  civilized 
countries.  Investigations  made  by  Jakob,^  Hillenberg,-  Overland,^ 
and  others  have  show^n  that  in  villages,  where  a  case  of  open  tuber- 
culosis had  not  been  seen  for  many  years,  the  people  living  under 
good  economic  and  hygienic  surroundings,  and  where  the  milk  supply 
was  practically  free  from  tuberculous  contamination,  25  per  cent,  of 
the  school  children  and  about  45  per  cent,  of  the  adults  gave  positive 
reaction?  to  tuberculin,  indicating  that  they  had  not  escaped  tuber- 
culous infection.  Here  we  find  that  the  effect  of  infection  is  only  an 
altered  reactivity  to  tuberculin,  and  not  phthisis.  The  reasons  for 
this  phenomenon  wdll  be  discussed  later  on. 

Tuberculosis  among  Primitive  Peoples  and  Races. — The  only 
regions  free  from  tuberculosis  appear  to  be  those  inhabited  by  primitive 
peoples  who  have  not  come  in  contact  with  civilization.  Thus,  the 
American  Indian,  before  the  advent  of  the  white  man  on  this  continent, 
knew  nothing  of  the  disease,  as  was  shown  by  Woods  Hutchinson,* 
Hrdlicka,^  and  others.  Nor  do  the  savage  and  barbarian  races  of 
Central  Africa  and  Asia  seem  to  have  had  experience  wdth  tuberculosis, 
until  the  whites  brought  it  to  them.  Among  these  primitive  peoples 
the  tuberculin  reaction  is  always  negative,  and  autopsies  made  on 
their  dead  reveal  no  active  or  healed  tuberculous  lesions,  as  is  the 
case  with  newborn  infants  among  Europeans.  But  it  appears  that  as 
soon  as  these  peoples  come  into  contact  with  civilized  man  they  are 
infected  in  large  numbers.  This  was  observed  among  the  American 
Indians,  the  native  tribes  of  Australasia  and  Africa,  etc.  The  application 
of  the  tuberculin  test  among  these  races  by  Calmette,''  MetchnikofF,'' 
Zieman,^  and  others  has  shown  clearly  that  the  frequency  of  tuber- 
culous infection  depends  directly  on  their  contact  with  civilization. 
It  is  altogether  absent  or  extremely  rare  among  those  races  who  have 
recently  met  the  white  man,  but  the  proportion  grows  in  direct  ratio 
to  the  intensity  of  immigration  of  European  settlers,  and  with  com- 
mercial interchange  between  them  and  civilized  humanity.  It  is  also 
evident  that  their  immunity  from  this  disease  before  the  advent  of 
the  white  man  was  not  due  to  racial  or  climatic  conditions,  as  was 
suggested  by  some  earlier  writers,  but  solely  to  the  absence  of  tubercle 
bacilli,  because  as  soon  as  these  are  imported,  the  natives  display  a 
striking  vulnerability  to  the  disease,  which  is  greater  the  longer  they 
have  been  protected  against  the  importation  of  tubercle  bacilli. 

1  Die  Tuberkulose  unci  die  hygienische  Misstande  auf  dem  Lande,  Berlin,  1911. 

2  Tuberkulosis,  1911,  x,  254. 

'  Internat.  Zentralblatt  filr  Tuberkulose,  1914,  viii,  635. 

4  New  York  Med.  Jour.,  1907,  Ixxxvi,  624. 

5  Tuberculosis  among  Certain  Indian  Tribes  of  the  United  States,  Washington,  1909. 

6  Ann.  de  I'instit.  Pasteur,  1912,  x.xvi,  497. 
'Ibid.,  1911,  XXV,  785. 

8  Centralblatt  f.  Bakteriologie,  1913,  Ixx,  118. 


62  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

Racial  Differences  in  Susceptibility  to  Tuberculous  Infection. — 

A  study  of  the  epidemiology  of  tuberculosis  also  teaches  that  the 
dangers  of  tuberculous  infection  depend  on  the  length  of  time  a  people 
have  been  exposed  to  the  disease.  Thus,  when  primitive  peoples, 
who  have  never  been  affected  with  this  disease  come  into  tubercle- 
laden  surroundings,  they  are  socn  infected  and  the  disease  runs  an 
acute  and  fatal  course  in  nearly  all  cases.  This  is  often  the  case  with 
savages  and  barbarians  brought  to  Europe  or  America :  They  almost 
invariably  acquire  tuberculosis  and  succumb  in  a  short  time.  The 
American  Indians,  coming  in  contact  with  the  whites  and  incidentally 
with  the  tubercle  bacillus,  are  being  decimated  by  the  disease  which 
runs  an  acute  and  fatal  course  among  them,  and  the  same  is  true  of 
the  negro  population  in  this  country. 

A  drastic  illustration  has  been  reported  by  Cummins^  from  Egypt 
where  the  Sudanese  soldier,  recruited  from  tribes  among  which  tuber- 
culosis is  practically  unknown,  is  much  more  liable  to  tuberculosis 
than  the  Egyptian  soldier  who  has  been  raised  in  a  region  where 
the  disease  has  been  quite  common  for  centuries.  In  former  times 
slaves  of  the  Sudanese  race  were  the  cheapest  in  the  market  because 
it  was  assumed  that  a  large  number  would  contract  the  disease  and 
die. 

This  is  exemplified  again  by  the  conditions  observed  among  the 
immigrants  to  the  United  States.  The  Irish  and  Sicilian  immigrants, 
and  to  a  lesser  extent  the  Hungarians,  Slavonians,  and  Scandinavians, 
mostly  hail  from  agricultural  parts  of  their  native  country  where  they 
have  known  very  little  of  tuberculosis.  In  this  country,  working  in 
closed  factories,  and  coming  in  contact  with  tuberculous  fellow-work- 
men, many  soon  contract  the  disease  which  runs  an  acute  course, 
terminating  fatally  in  a  large  proportion  of  cases.  Among  immigrants 
coming  from  countries  or  cities  where  they  have  been  exposed  to 
infection  for  generations,  as  is  the  case  with  the  English,  Germans, 
and  especially  the  Jews,  the  rates  of  tuberculous  mortality  are  much 
lower. 

When  speaking  of  race  influence  on  the  incidence  and  mortality 
from  tuberculosis,  the  facts  just  mentioned  must  always  be  borne  in 
mind.  Tuberculosis  appears  not  to  be  a  racial  problem — there  are 
no  races  which  are  more  or  less  vulnerable  to  the  disease  because  of  their 
ethnic  peculiarities,  such  as  height  of  the  body,  color  of  the  skin,  eyes 
and  hair,  or  other  somatic  or  morphological  traits  which  distinguish 
one  race  from  another.  Every  human  race  or  ethnic  group  when  first 
meeting  with  tubercle  bacilli  is  as  vulnerable  as  another.  It  is  only 
after  they  have  been  exposed  for  many  generations  to  the  disease 
that  they  acquire  a  certain  power  of  resistance  against  infection  which, 
though  occurring  in  almost  everyone  who  has  been  exposed  to  infection, 
is  less  liable  to  cause  disease  than  in  races  which  present  virgin  soil 

1  Trans.  Soc.  Trop.  Med.  and  Hyg.,  1911-1912,  v,  245. 


GEOGRAPHICAL  DISTRIBUTION 


63 


to  the  bacilli.    The  mechanics  of  this  acquired  immunity  will  be  dis- 
cussed later  on. 

Mortality  from  Pulmonary  Tuberculosis  per  100,000  Population. 


1861 

1866 

1871 

1876 

1881 

1886 

1891 

1896 

1901 

1906 

to 

to 

to 

to 

to 

to 

to 

to 

to 

to 

Country. 

1865. 

1870. 

1875. 

1880. 

1885. 

1890. 

1895. 

1900. 

1905. 

1910. 

United  States  . 

171 

147 

England  and  Wale 

s  '.     253 

245 

222 

204 

183 

164 

146 

132 

122 

111 

Scotland 

.  252 

262 

248 

229 

211 

189 

174 

165 

145 

Ireland  . 

183 

191 

200 

208 

212 

214 

213 

215 

191 

Australia  . 

122 

121 

107 

94 

89 

75 

New  Zealand  . 

91 

84 

81 

78 

70 

62 

*Ontario  Province 

125 

116 

114 

141 

129 

113 

Germany  . 

361 

348 

314 

224 

194 

186 

1.59t 

Prussia  . 

317 

312 

290 

247 

208  ■ 

191 

162 

Bavaria . 

287 

262 

243 

214t 

Saxony  . 

251 

251 

244 

236 

212 

194 

154 

135t 

Baden  . 

312 

297 

278 

244 

217 

183 

*Austria 

377 

393 

383 

394 

345 

340 

305 

Switzerland 

200 

209 

213 

199 

190 

189 

176t 

Netherlands 

189 

165 

133 

125 

^Belgium  . 

'.      305 

305 

335 

323 

301 

165 

142 

118 

102t 

France  . 

255 

249 

265 

277t 

Italy   . 

137 

100 

106 

116 

123t 

Spain 

148 

135 

Denmark 

262 

249 

231 

200 

160 

149 

134t 

Norway 

108 

126 

140 

144 

173 

206 

196 

200t 

Finland 

374 

414 

367 

255 

256 

261 

273 

291 

Serbia  . 

251 

231 

280 

297 1 

♦Hungary 

364 

397 

374 

Chile   . 

235 

269 

Japan  . 

101 

136 

145 

146 

154t 

Notes. — All  figures  refer  to  pulmonary  tuberculosis,  except  those  marked  *  which  include  all 
forms  of  tuberculosis. 

Figures  in  the  last  column  marked  f  are  only  for  1906-1908. 

Geographical  Distribution. — Fifty  years  ago  Hirsch  in  his  classical 
study  of  Geographical  and  Historical  Medicine  arrived  at  the  con- 
clusion that  tuberculosis  is  a  disease  of  all  times  and  all  countries. 
With  our  present  knowledge  we  have  not  discovered  any  proofs  to 
the  contrary.  Observations  in  every  part  of  the  habitable  globe  show 
that  the  presence  or  absence  of  the  disease  is  determined  less  by 
geographical  location  or  climatic  phenomena  than  by  social  and 
economic  conditions  and,  above  all,  by  the  presence  or  absence  of  the 
tubercle  bacillus.  We  have  shown  in  the  preceding  pages  that  its 
absence  in  certain  countries  has  not  been  due  to  either  an  immunity 
of  the  population,  nor  to  the  climate  in  which  they  live,  nor  to  the 
altitude  on  which  they  have  been  located.  Indeed,  it  is  obvious  that 
as  soon  as  the  tubercle  bacilli  are  introduced  among  any  people  in 
any  geographical  location,  the  disease  is  not  slow  in  making  its  appear- 
ance. The  comparative  absence  of  tuberculosis  in  the  Rockies,  the 
Andes,  and  other  mountainous  regions  in  former  times  was  apparently 
due  to  the  scarcity  of  population  and  the  peculiarity  of  the  occupations 
there  pursued.  In  the  mountainous  regions  of  the  United  States 
tuberculosis  was  scarce  before  consumptives  began  to  immigrate  in 
search  of  health.  Brown,  investigating  conditions  in  El  Paso,  Texas, 
found  that  the  testimony  of  physicians  is  to  the  effect  that  deaths  due 
to  this  disease  are  rare  among  the  indigenous  population;  E.  A. 
Sweet^  finds  this  to  be  true  of  the  entire  southwest  region  of  this 


1  Public  Health  Reports,  1915,  xxx,  1059,  1147,  1225. 


64 


THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 


country,  and  Cattermole  confirmed  it  in  Colorado.     But  it  appears 
that  the  infection  of  people  li^-ing  under  good  sanitary,  and  above  all, 

economic  conditions  does  not  always  produce  phthisis,  especially  in 

regions  where  outdoor  life  is  the  vogue. 

Death-rates  from  Pulmonary  TrsERcuLosis  per  100,000  Population 
IN  Various  Cities. 

1881  1886             1891  1896  1901  1906 

to  to                 to  to  to  to 

City.                                         1885.  1890.             1895.  1900.  1905.  1910. 

New  York 398  350             286  242  215  197 

Chicago 180  177             176  154  152  162 

Boston 411  377             289  240  217  175 

Philadelphia      .....     311  269             233  210  215  206 

London 222  197             185  175  157  132 

Edinburgh 212  191             180  187  157  114 

Glasgow 311  250             227  195  170  140 

DubUn 346  341             335  317  309  268 

Belfast 382  402             382  329  307  235 

Paris 441  440             409  379  390  374 

Berlin .  .                 .  .  .  .  .  .  188 

Hamburg .  .              238  200  169  137 

Munich 389  348             312  303  269  226 

Dresden 376  334             283  247  224  180 

Breslau 331  313             342  321  318  271 

Amsterdam 238  234             204  185  144  138 

Rotterdam 219  192             188  170  133  127 

The  Hague 199  179             163  160  128  124 

Vienna 685  576             474  381  336  274 

Prague 728  609             512  472  525  385* 

Budapest 715  591             434  376  367  340 

Trieste 522  491             439  402  396  369 

Christiania 320  287             282  274  229  183* 

Stockholm 344  303             269  246  227  230 

Copenhagen 273  246              198  180  144  136 

Petrograd 547  449             384  321  305  301 

Moscow 411  393             391  324  268  258 

Milan 335  307             284  20'4  232  220 

Turin 240  222             250  234  225  "  183 

Sydney 193  157             119  98.  98  72 

Melbourne 233  213             182  153  139  109 

Montreal 282  256              235  250  197  163* 

Toronto 203  207             242  234  174 

Rio  de  Janeiro        ....     548  . .              446  474  455  402 

Figures  marked  *  indicate  that  the  death-rate  in  the  last  column  is  onlj-  for  1910. 


Incidence  among  Rural  and  Urban  Residents. — Of  greater  influ- 
ence than  climate  and  altitude  appears  to  be  life  in  the  city  as  com- 
pared with  life  in  the  country  as  regards  the  morbidity  and  mortality 
from  tuberculosis.  It  appears  that  country  dwellers,  while  not  exempt 
from  infection  with  tubercle  bacilli,  are  yet  less  likely  to  suft'er  from 
phthisis  than  the  city  residents.  Thus,  the  average  death-rate  from 
tuberculosis  of  the  lungs  in  the  registration  area  of  the  United  States 
during  the  decade  ending  with  1909  was  154.7  per  100,000  population, 
but  in  the  cities  of  the  registration  area  the  rate  was  177.4  against 
a  rural  death-rate  of  but  124. 1 .  These  differences  would  be  even  greater 
if  we  excluded  the  rural  centres  in  which  factories,  mills,  coal  mines, 


SOCIAL  AND  ECONOMIC  FACTORS  65 

etc.,  are  located  and  where  the  workers  live  to  all  intents  and  purposes 
under  the  same  conditions  as  those  in  the  cities.  These  differences  in 
the  mortality  from  phthisis  are  found  in  every  country  where  vital  statis- 
tics are  gathered.  In  England  and  Wales  the  mortality  per  million 
population  was  in  1913:  London,  1335;  England  and  Wales,  1004; 
rural  districts,  742;  all  urban  districts,  1075.  The  table  on  page  64 
shows  the  high  mortality-rates  from  this  disease  in  large  cities  in  various 
parts  of  the  world.  When  compared  with  the  rates  for  the  entire 
country,  as  given  on  page  63,  the  differences  are  clear. 

The  establishment  of  sanatoriums  for  consumptives  in  rural  districts 
during  recent  years  has  apparently  increased  the  mortality  from  this 
disease  in  certain  country  districts.  Thus,  in  1910  the  death-rates  from 
pulmonary  tuberculosis  in  the  State  of  New  York  were:  in  cities,  165.7; 
and  in  the  rural  districts,  120.1,  while  in  Colorado,  the  Mecca  of 
American  consumptives,  the  rates  were:  cities,  288.2;  in  rural  districts, 
155.9.  It  is  thus  evident  that  with  superior  climate  and  altitude, 
Colorado  has  a  higher  mortality  from  pulmonary  tuberculosis  than 
the  State  of  New  York,  Of  course,  the  reason  is  that  most  of  the  fatal 
phthisis  in  Colorado  is  imported. 

Wherever  available,  statistics  show  clearly  that  there  is  more 
fatal  tuberculosis  in  cities  than  in  the  country.  The  reasons  for  this 
disparity  are  to  be  sought  not  only  in  the  outdoor  life  which  country 
dwellers  indulge  in  more  than  city  people,  but  more  in  the  difference 
in  social  and  economic  conditions. 

Social  and  Economic  Factors. — There  is  no  question  but  that  infec- 
tion with  tubercle  bacilli  is  to  a  large  extent  influenced  by  social  and 
economic  conditions;  but  it  appears  from  available  evidence  that  the 
development  of  phthisis  is  almost  altogether  dependent  on  these  factors. 
Thus,  we  find  among  the  so-called  well-to-do,  the  cutaneous  tuberculin 
reaction  only  rarely  reveals  hypersensitiveness  among  infants  and 
children.  Schlossmann  even  says  that  a  positive  skin  reaction  is 
hardly  ever  found  among  the  children  of  his  rich  clientele,  indicating 
that  they  are  free  from  infection.  The  experience  of  American 
physicians  appears  to  be  to  the  same  effect,  though  we  do  not  have 
data  about  inoculation  of  a  large  series  of  well-to-do  children  in  this 
or  any  other  country.  It  is,  however,  a  rule  among  pediatrists  to 
place  great  reliance  on  the  tuberculin  test  in  children.  That  this  is 
justified  in  the  case  of  children  of  prosperous  parentage  may  be  true, 
but  whether  in  older  children  a  positive  skin  reaction  is  exceptional 
is  open  to  question.  When  children  attend  school,  and  later  when  they 
go  out  into  the  world,  meeting  all  sorts  and  conditions  of  men,  they 
are  no  longer  sheltered  against  infection,  and  most  of  them,  in  fact, 
do  become  infected  sooner  or  later. 

The  high  proportion  of  positive  reactions  obtained  among  children 

and  adults  in  rural  districts  in  Germany  and  Scandinavia,  where 

infection  has  taken  place  despite  the  absence  of  known  open  cases  of 

tuberculosis,  and  even  where  bovine  infection  could  be  excluded,  appears 

5 


66  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

to  confirm  this  view.  In  fact,  it  is  very  rare  to  find  an  adult  in  a 
large  city  who  does  not  show  a  positive  skin  reaction  to  tuberculin, 
irrespective  of  his  social  or  economic  condition. 

Among  the  millions  of  poletariat  in  large  modern  industrial  cities 
infection  appears  to  be  most  rampant.  All  reliable  tests — autopsies 
and  tuberculin — have  shown  that  very  few  escape  infection,  and  the 
clinics,  sanatoriums  and  hospitals  for  tuberculous  patients  derive  their 
clinical  material  mainly  from  these  strata  of  population.  A  study  of 
the  mortality-rates  also  shows  that  these  are  the  people  who  are  most 
likely  to  succumb  to  tuberculosis.  One  has  only  to  glance  over  the 
maps  of  New  York  City  prepared  under  the  auspices  of  Herman  M. 
Biggs  to  be  convinced  that  poverty  and  tuberculosis  go  hand-in-hand. 
The  blocks  inhabited  by  the  rich  show  exceedingly  few  deaths  from 
this  disease,  while  those  inhabited  by  the  artisans,  the  laborers  and 
the  poor — the  "slums"- — are  appallingly  studded  with  cases  of  phthisis. 

Illustrations  from  other  cities  are  not  wanting.  In  Hamburg  the 
death-rates  from  tuberculosis  are  in  inverse  ratio  to  the  amount  of 
income  tax  paid  by  the  various  groups  of  population.  In  Paris,  Ber- 
tillon  found  that  in  the  very  rich  district  Elysee  the  mortality  from 
tuberculosis  is  the  least  in  the  city;  it  is  somewhat  higher  in  the  rich 
Opera  district;  higher  in  the  very  well-to-do  district  Luxembourg; 
higher  yet  in  the  well-to-do  Temple  district;  very  high  in  the  poor 
Reuilly  district,  and  highest  in  the  Twentieth  Arrondissement,  where 
the  inhabitants  are  exceedingly  poor.  In  Glasgow,  according  to  Glaister, 
the  mortality  is  higher  among  families  living  in  one-room  apartments 
than  in  those  who  live  comfortably  in  several  rooms.  In  Edinburgh 
A.  Maxwell  Williamson^  found  that  the  number  of  cases  of  tuberculous 
disease  increases  in  proportion  as  the  house  accommodations  become 
limited.  "Pulmonary  tuberculosis  is  a  disease  which  in  70  or  80  per 
cent,  of  cases  occurs  in  houses  of  three  rooms  and  under;  the  number 
of  cases  is  larger  in  two-room  houses  than  in  three;  larger  in  houses 
of  one  room  than  in  two;  and  the  number  of  cases  of  the  disease 
increases  almost  in  direct  proportion  to  the  number  of  small  houses 
in  any  district  or  ward  of  a  city."  The  relation  of  phthisis  to  over- 
crowding is  seen  clearly  in  the  industrial  cities  of  the  United  States. 

Similar  investigations  as  to  the  relations  of  wages  to  morbidity 
and  mortality  of  tuberculosis  have  shown  that  higher  wages  mean  less 
of  the  disease  (see  p.  70).  The  experience  of  life  insurance  companies 
is  to  the  effect  that  industrial  policy  holders  who  pay  small  weekly 
premiums  are  more  likely  to  succumb  to  the  disease  than  those  who 
hold  "ordinary"  policies  paying  annual  premiums.  From  figures 
supplied  by  Dr.  Lee  K.  Frankel  it  is  clear  that  the  experience  of  the 
Metropolitan  Life  Insurance  Company  is  in  agreement  with  the  view 
just  expressed.  Those  who  insure  their  lives  for  small  sums,  paying 
small  weekly   premiums',   technically  called   "industrial   insurance," 

1  Brit.  Jour,  of  Tuber.,  1915,  ix.  111. 


INFLUENCE  OF  AGE  67 

are  more  likely  to  succumb  to  pulmonary  tuberculosis  than  those  who 
insure  in  the  ''ordinary  department,"  for  sums  not  less  than  $1000, 
and  paying  large  annual  premiums.  During  1914  the  death-rates 
per  100,000  were  as  follows: 

"Ordinary"  "Industrial" 

Age  period.  policy  holders.  policy  holders. 

20  to  24 110.32  339.7 

25  to  34 99.18  390.4 

35  to  44 104 .  73  352 . 3 

45  to  54 108.95  496.9 

55  to  64 .      .      .  106,68  373.5 

65  to  74 113.71  219.2 

75  and  over 168.2 

In  Europe  it  was  found  that  the  larger  the  amount  for  which  the 
person  is  insured,  the  less  likely  is  he  to  succumb  to  tuberculosis. 

The  slums  of  large  cities  contain  "lung"  blocks  which  have  been 
pictured  in  such  sombre  colors  in  the  popular  tuberculosis  literature. 
Of  course,  the  bad  housing  conditions  are  responsible  to  a  large  extent. 
But  it  must  be  remembered  also  that  "  a  slum  is  not  constituted  solely 
of  broken-down  houses,  but  also  of  broken-down  occupants,  and  it  is 
perhaps  easier  to  remedy  the  one  than  the  other,"  says  John  Glaister.^ 

Thus,  we  have  a  vicious  circle  in  the  economics  of  tuberculosis. 
Poverty  brings  about  congestion  and  overcrowding,  enhancing  the 
chances  of  massive  infection;  it  also  compels  its  victims  to  work  in 
unsanitary  factories,  mills  and  workshops  and  at  trades  which  are 
dangerous  in  this  regard.  The  vitality  is  depressed  and  the  powers  of 
resistance  reduced  as  a  result  of  insufficient  and  improperly  prepared 
food,  so  that  infection  more  often  terminates  in  phthisis  than  among 
those  who  are  higher  in  the  social  scale. 

However,  that  the  well-to-do  and  rich  do  not  escape  is  evident  when 
we  glance  into  the  modern  private  sanatoriums  which  derive  their 
clientele  from  those  who  can  pay  more  than  fifty  dollars  per  week, 
not  including  medical  attendance.  The  resorts  in  Europe  are  also 
filled  with  rich  consumptives,  as  can  be  seen  in  Switzerland  and  the 
Riviera.  Of  course,  this  shows  that  not  all  well-to-do  individuals 
live  wisely,  even  though  they  can  well  afford  to  do  so. 

Influence  of  Age. — In  considering  the  infiuence  of  age  on  the  inci- 
dence of  tuberculosis  we  must  again  differentiate  tuberculous  infection 
from  morbidity  and  from  mortality,  and  also  the  various  forms  of  the 
disease. 

The  newborn  infant  is  free  from  tuberculosis  as  we  have  shown; 
infection  takes  place  during  the  lifetime  of  the  individual  who  is  exposed 
to  the  bacilli.  We  have  already  seen  that  those  living  in  a  tuberculous 
milieu  do  not  escape,  and  during  the  first  year  about  15  per  cent,  are 
infected;  during  the  first  five  years  about  50  per  cent.,  and  at  the  age 
of  fourteen  over  80  per  cent,  are  infected.  Even  children  of  non- 
tuberculous  parentage  are  infected   with  tuberculosis  to  the  same 

1  Practitioner,  1913,  xc,  344, 


68  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

extent  as  those  of  tuberculous  stock,  but  not  at  such  an  early  age, 
and  when  reaching  adolescence  the  difference  is  not  so  pronounced 
as  would  be  expected  a  'priori. 

Mortality  from  Tuberculosis  in  the  Registration  Area  of  the  United 
States  per  10,000  Living  at  the  Given  Age  and  Se.x,  1910-1913. 


Age. 

Pulmonary  tuberculosis. 
^Nlales.                   Females. 

All  other  forms  of 

tuberculosis. 

Males.                Females 

Oto    1 6.73                   5.68 

13.76                   12.14 

1    . 

4.72                    4.00 

11.78                  10.64 

2   . 

2.14                    1.97 

6.13                    5 . 53 

3    . 

1.44                    1.41 

3.95                   3.84 

4  . 

1.00                    1.16 

2 . 90                   2 . 78 

5   . 

0.97                    0.94 

2.10                    1.54 

6  . 

0.92                    0.84 

2.01                     1.37 

7  . 

0.85                    1.19 

1 . 83                   1 . 95 

8  . 

0.63                    1.26 

1.36                   2.07 

9   . 

0.98                   1.31 

2.11                   2.14 

10  to  14   . 

1 . 22                    2 . 94 

1.15                    1.35 

15  to  19   . 

7.96                 11.09 

1.72                   2.09 

20  to  24   . 

16.27                 17.66 

2.10                    2.26 

25  to  29   . 

18.98                 19.33 

2.12                    2.10 

30  to  34  . 

21.70                 18.62 

2.08                    2.01 

35  to  39   . 

23,13                 16.22 

2.09                   1.89 

40  to  44   . 

23.47                  14.25 

2 . 07                   1 . 69 

45  to  49   . 

23.32                 11.99 

2.02                   1.63 

50  to  54  . 

21.68                  11.19 

2.04                   1.63 

55  to  59   . 

22.99                  11.80 

2.47                   1.96 

60  to  64  . 

22.13                  12.39 

2.56                   1.92 

65  to  69   . 

21.00                  14.25 

2.45                    2.22 

70  to  74   . 

20.11                 15.87 

2.68                    2.37 

75  to  79   . 

18.02                 16.07 

2.41                    2.70 

80  to  84  . 

13 .64                 13 . 24 

2.02                    2.20 

85  to  89   . 

12.48                 10.23 

,    2.38                    2.23 

90  to  94   . 

9.71                   6.58 

1.21                     1.25 

95  and  over 

10.37                   6.71 

1.52 

The  morbidity  from  the  disease  is  greatly  influenced  by  age.  During 
the  first  two  years  of  life  tuberculosis  is  very  frequently  encountered 
in  the  form  of  acute  miliary  tuberculosis,  and  tuberculosis  of  the  joints, 
bones,  and  glands.  Between  two  and  ten  years  of  age  we  mostly 
find  the  milder  forms  of  osseous,  glandular,  and  articular  tuberculosis 
and  chronic  pulmonary  tuberculosis  is  very  rare.  Only  after  the  age 
of  ten  does  the  latter  form  of  tuberculosis  make  its  appearance,  and 
after  fifteen  years  of  age  it  becomes  the  menace  of  society — the  pro- 
verbial ''white  plague" — causing  more  misery  than  any  other  disease. 

The  disease  is,  however,  for  lack  of  reliable  morbidity  statistics,  best 
gauged  b}'  a  study  of  the  mortality -rates.  From  the  ab()\-e  table  and 
page  09  it  is  seen  that  there  are  two  maximums  of  mortalitx'.  The  first 
during  the  first  two  years  of  life;  while  beginning  with  the  third  year 
tuberculosis  becomes  a  very  infrequent  cau.sc  of  death  until  the  tenth 
year  is  reached,  when  it  again  begins  to  rise,  reaching  its  full  height  at 
twenty  years,  and  keeps  at  that  high  k^-el  with  slight  finctuations  until 
sixty  years,  when  there  is  again  a  slight  decline, 


INFLUENCE  OF  SEX  69 

As  has  been  pointed  out  by  Ranke/  the  rate  of  infection  with 
tuberculosis  does  not  follow  closely  the  rate  at  which  the  disease  kills. 
We  have  shown  above  that  infection  begins  during  the  first  year 
of  life,  keeps  on  increasing  during  every  subsequent  year  until  at  the 
age  of  twenty  very  few  individuals  are  found  who  have  escaped  it. 
The  mortality  is  comparatively  high  during  the  first  year  of  life, 
but  then  declines,  so  that  between  three  and  twelve  years,  just  the 
period  when  most  infections  occur,  the  number  of  deaths  is  the  least, 
and  only  after  the  fifteenth  year  does  the  mortality  rise  to  its  highest 
point  and  keeps  at  it  throughout  life.  The  bearings  of  these  facts 
on  the  problems  of  phthisiogenesis  and  prophylaxis  will  appear  in 
other  sections  of  this  book. 

Influence  of  Sex. — From  the  table  on  page  68  we  find  that  during 
the  first  six  years  of  life  the  mortality  from  pulmonary  tuberculosis 
is  somewhat,  though  not  very  materially,  less  among  females  than 
among  males.  After  the  sixth  year  the  rates  among  females  are  higher 
than  among  males  of  the  corresponding  age  groups.  Between  fifteen 
and  thirty  years  of  age  the  difference  in  favor  of  the  males  is  striking. 
After  thirty  years  the  females  again  show  lower  mortality-rates  which 
keep  up  until  the  end  of  natural  human  life.  The  total  mortality  is 
less  among  females  than  among  males,  a  fact  which  has  been  observed 
in  all  countries  where  vital  statistics  are  available.  In  England  and 
Wales  the  mortality  from  phthisis  in  1913  was:  Among  the  total 
population  9.81  per  10,000;  among  males  11.54,  and  among  females 
only  8.18. 

Various  explanations  have  been  offered  for  this  disparity  in  the  mor- 
tality from  phthisis  between  the  two  sexes.  It  has  been  suggested  that 
the  more  hazardous  occupations  in  which  men  are  mainly  engaged 
reduced  their  resistance  and  predisposed  them  to  phthisis;  or  when 
becoming  sick  with  the  disease  the  chances,  of  recovering  are  less  in 
the  case  of  men  who  have  to  work  for  their  support  as  well  as  for 
those  depending  on  them.  But  during  the  ages  of  fifteen  to  forty-five, 
when  menstruation,  pregnancies  and  lactation  undermine  the  resisting 
powders  of  women,  it  would  be  but  natural  that  the  mortality  from 
phthisis  should  be  high  among  them.  Vital  statistics  in  some  countries 
seem  to  support  this  view,  but  in  the  United  States  the  higher  mor- 
tality among  the  women  keeps  up  only  until  the  age  of  thirty,  when  it 
again  declines  as  compared  with  the  men. 

It  appears  to  me  that  the  higher  mortality  from  phthisis  among 
women  between  fifteen  and  thirty  in  the  United  States  is  to  be  attrib- 
uted to  the  large  number  engaged  in  gainful  occupations.  This  is  con- 
firmed by  the  census  returns  showing  that  among  all  classes  of  popula- 
tion, male  and  female,  ten  years  of  age  and  over  without  regard  to 
occupation,  the  proportion  of  deaths  from  tuberculosis  is  56  per  cent, 
males  and  44  per  cent,  females.    When  women  enter  the  occupations 

I  Miinch.  med.  Wchnsehr.,  1914,  Ixi,  2099. 


70  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

to  earn  a  living,  as  B.  S.  Warren^  has  shown,  the  proportion  is  reversed 
and  the  difference  much  greater.  Thus,  among  salesmen  tuberculosis 
constitutes  15.8  per  cent,  of  all  deaths,  as  against  31.1  per  cent,  among 
sales^vomen;  among  silk-mill  weavers,  men  19.7  per  cent,  and  women 
38.3  per  cent.;  among  woollen-mill  operatives;  males  22.2  per  cent, 
and  females  29.2  per  cent.;  clerks  and  copyists,  males  29.2  per  cent, 
and  females  31.8  per  cent.;  and  boot  and  shoemakers,  males  13.3 
per  cent,  and  females  31.8  per  cent.  It  thus  appears  that  it  is  more  a 
problem  of  industrial  conditions  than  of  sexual  differences.  In  fact, 
women  do  not  bear  hard  work  under  deleterious  conditions  as  well 
as  men,  and  succumb  to  phthisis  in  greater  numbers  when,  in  addition 
to  their  physiological  functions,  they  become  bread-winners. 

Mortality-rates  from  Pulmonary  Tuberculosis. — It  is  impossible 
at  present  to  give  with  certainty  the  extent  of  tuberculous  morbidity 
in  any  population.  Even  in  cities  where  registration  of  this  disease 
is  compulsory,  the  data  collected  in  this  manner  are  not  complete, 
and  we  do  not  know  the  exact  number  of  persons  suffering  from  active 
tuberculosis.  The  statistics  published  by  certain  benevolent  and  indus- 
trial societies  are  also  inconclusive  because  they  concern  only  certain 
groups  of  people,  and  the  results  cannot  be  applied  to  the  general  popu- 
lation. Attempts  have  been  made  to  ascertain  the  morbidity-rates 
from  tuberculosis  by  multiplying  the  number  of  deaths  occurring 
in  a  given  region  by  the  average  duration  of  the  disease.  Thus,  there 
annually  occur  about  160,000  deaths  due  to  tuberculosis  in  the  United 
States;  in  Germany  over  100,000;  in  France  70,000;  in  England  and 
^Yales  over  50,000,  etc.  But  attempts  at  multiplying  these  numbers 
by  the  number  representing  the  average  duration  of  the  disease  and 
thus  finding  the  actual  number  of  sick  have  met  with  failure  because 
there  is  no  agreement  as  to  the  average  length  of  phthisis.  Indeed, 
it  has  been  estimated  at  from  one  to  ten  years  by  different  authors. 

The  extent  of  the  disease  is  therefore  best  gauged  by  the  number 
of  deaths  it  causes  in  a  given  population.  The  table  on  page  63 
gives  the  mortality  per  100,000  population  in  different  countries. 
When  in  connection  with  these  figures  we  bear  in  mind  that  one-third 
of  all  the  deaths  during  the  prime  of  life,  between  fifteen  and  forty,  are 
due  to  tuberculosis,  of  which  over  90  per  cent,  is  phthisis,  we  realize 
the  enormity  of  the  problem  presented  by  tuberculosis  and  the  reason 
why  it  has  been  considered  the  most  important  of  diseases  with  which 
humanity  has  to  cope. 

The  differences  in  the  mortality-rates  for  the  different  countries 
are  due  to  various  causes,  mainly  the  intensity  of  concentration  of 
population  in  cities,  the  character  of  the  occupations  pursued  by  the 
people  and  other  causes  which  have  already  been  discussed. 

Decline  in  the  Mortality  from  Tuberculosis. — Another  point  brought 
out  by  the  figures  in  this  table  is  that  the  mortality  from  tuberculosis 

'  Trans.  Nat.  Assn.  Study  and  Prev.  Tuber.,  1913,  ix,  153. 


DECLINE  IN  THE  MORTALITY  FROM  TUBERCULOSIS       71 

has  been  declining  in  nearly  all  countries  where  statistics  are  available, 
excepting  in  Norway,  Ireland,  Serbia,  Spain,  France,  Italy,  Japan, 
Hungary,  etc.  This  decline  is  of  great  significance,  and  if  the  exact 
causes  were  ascertained  we  might  be  in  a  position  to  accelerate  it  so 
that  ultimately  the  disease  could  be  stamped  out  altogether. 

It  will  be  noted  that  in  England  the  mortality  from  phthisis  declined 
since  1861-1865  from  253  to  147  during  1906-1910.  A  glance  at 
Fig.  3,  showing  the  mortality  in  1851  as  compared  with  1912,  proves 
conclusively  that  the  mortality  has  declined.  The  same  is  true  of 
Scotland,  Australia,  Germany,  Austria,  etc.  For  the  United  States 
Frederick  L.  Hoffman's^  statistics  show  clearly  that  the  mortality 
from  tuberculosis  in  New  York,  Philadelphia,  Boston,  etc.,  has  been 
constantly  declining  during  the  past  one  hundred  years. 


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1            I        1 'js.-i— —  — |-/r 

1            1                 '    1             ' 

45 

40 

35 

30. 
o 
o 
o 

25  2 

a. 
u 

20'^ 

15 

10 


5-10      10-15     15-20     20-25     25-35     35-45     45-55     55-65     65-75    75  AND  OVER 
YEARS 


Fig.  3. — Mortality  from  phthisis  by  age  groups  in  England  and  Wales  per  10,000 
living,  showing  the  decrease  from  1851  to  1912.  Dotted  line,  mortality  during  1851- 
1856;    black  line,  mortality  in  1912. 

What  are  the  causes  of  this  decline  in  the  tuberculosis  mortality? 
All  authorities  agree  that  it  is  mainly  due  to  the  causes  which 
have  been  operative  in  reducing  the  general  mortality;  in  banishing 
or  abating  the  malignancy  of  most  other  infectious  diseases.  Among 
these  factors  are  largely  to  be  considered  the  improvements  in  the 
sanitary  and  hygienic  conditions  under  which  the  bulk  of  the  people 
live  at  present.  It  is  also  to  be  considered  that  modern  factory  legis- 
lation, the  improvements  in  the  economic  conditions  of  the  people, 
the  shorter  hours  of  work,  etc.,  which  are  characteristic  of  the  present, 
as  compared  with  conditions  during  the  first  half  of  the  nineteenth 


1  Trans.  Nat.  Assn.  Study  of  Prev.  Tuber.,  1913,  ix,  101. 


72  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

century,  have  been  instrumental  in  reducing  the  general  mortality 
and  of  phthisis  as  well. 

The  Effect  of  the  Special  Campaign  against  the  Spread  of  the 
Disease. — Most  authors  when  speaking  of  the  reduction  in  the  tubercu- 
losis mortality'  point  at  once  at  the  special  measures  which  have  been 
taken  to  combat  this  disease  as  the  sole  factor  in  this  direction.  In 
fact,  the  figures  compiled  in  the  tables  on  p.  63  and  64  are  always 
brought  forward  in  proof  of  the  effectiveness  of  the  antituberculosis 
campaign  which  has  been  so  aggressively  waged. 

But  careful  studies  of  the  available  statistical  data  have  not  sus- 
tained this  contention.  In  England,  where  the  decline  has  been  more 
pronounced  than  in  any  other  country,  it  has  been  shown  by  competent 
statisticians  that  such  is  not  the  fact.  Karl  Pearson^  points  out  that, 
examining  available  data,  it  appears  that  the  death-rates  from  phthisis 
are  steadily  increasing  as  we  go  backward  to  1838.  Now,  this  could  not 
go  on  indefinitley  because  if  it  did,  every  individual  five  hundred 
years  ago  must  have  died  in  England  from  phthisis.  There  was 
assuredly  a  time  in  England  when  the  phthisis  rates  were  rising,  just 
as  they  have  recently  been  falling.  "'We  have  to  stretch  our  ideas 
of  time  a  little  and  we  should  realize  the  possibility  of  a  typical  epi- 
demic curve  in  the  frequency  of  phthisis.  Indeed,  the  mortality 
from  phthisis  in  England  has  been  declining  since  1838,  i.  e.,  long 
before  any  special  measures  had  been  taken  for  the  control  of  the  dis- 
ease, or  segregation  of  the  sources  of  infection — tuberculous  human 
beings  and  animals — had  been  attempted." 

Data  from  other  countries,  especially  where  the  disease  has  become 
a  menace  during  recent  years,  confirm  these  views.  During  the  first 
half  of  the  nineteenth  century  there  were  isolated  areas  in  Europe 
where  tuberculosis  was  rare,  but  with  the  segregation  o'f  the  popula- 
tion in  cities  during  recent  years,  and  the  introduction  of  modern  indus- 
trial conditions,  the  disease  has  made  its  appearance  and  rages  there 
with  greater  vigor  than  in  countries  where  the  disease  has  appeared 
before.  Thus,  the  tuberculosis  mortality  has  been  rising  in  Ireland, 
Norway,  Serbia,  Bulgaria,  Hungary,  Japan,  etc.,  during  the  same 
period  that  it  has  been  declining  in  England,  Germany,  etc.  There 
is  no  doubt  that  the  measures  taken  for  the  control  of  the  disease  in 
Norway  are  as  aggressive  and  advanced  as  those  taken  in  neighboring 
Denmark,  yet  in  the  former  the  mortality-rates  have  been  rising,  while 
in  the  latter  they  have  steadily  declined.  The  same  is  true  of  France 
when  compared  with  Belgium,  and  similar  analogies  can  be  made 
between  other  countries,  or  various  regions  of  any  single  country. 

It  appears  that  the  mortality-rates  from  tulierculosis  have  been 
declining  to  the  same  extent  as  the  general  mortality  from  all  causes, 
as  has  been  shown  clearly  by  many  comi)etent  statisticians.  Professor 
Walter  F.  Wilcox^  says  that  "to  show  that  the  campaign  against 

'  The  Fight  Against  Tuberculosis  and  the  Death-rate  from  Phthisis,  Lonrlon.  1911,  \).  0. 
2  Monthly  Bull.  New  York  Board  of  Health,  1910,  xxvi,  85. 


SPECIAL  CAMPAIGN  AGAINST  SPREAD  OF  THE  DISEASE     73 

tuberculosis  is  having  its  effects,  it  should  be  found  that  the  death- 
rates  from  that  disease  are  decreasing  faster  than  the  average  for  all 
other  causes."  But  a  test  of  this  question  with  statistics  for  the  mor- 
tality in  the  State  of  New  York  shows  that  the  result  is  a  negative  one. 
"No  influence  of  the  special  campaign  can  be  traced  in  the  figures. 
The  condition  in  Michigan  is  similar  to  that  in  New  York.  In  Indiana 
the  number  of  deaths  in  each  instance  has  decreased,  but  apparently 
the  proportion  of  those  from  tuberculosis  to  all  others  has  not."  In 
New  Jersey  and  Rhode  Island,  while  the  mortality  from  other  causes 
has  been  decreasing,  that  from  tuberculosis  has  been  increasing,  so 
that  the  comparative  proportion  of  the  latter  has  risen.  Pearson 
has  proved  incontrovertibly  that  since  the  campaign  has  been  waged 
in  England  against  tuberculosis  "the  rate  of  fall  in  the  death-rate 
from  phthisis,  instead  of  being  accelerated,  has  been  retarded." 

Statisticians  are  not  alone  in  this  opinion.  In  a  posthumous  paper 
by  Robert  Koch^  he  states  that  the  special  measures  taken  for  the 
control  of  tuberculosis,  such  as  segregation  of  consumptives,  the  erec- 
tion of  sanatoriums,  etc.,  are  not  to  be  taken  as  the  sole  factors  which 
have  been  instrumental  in  reducing  the  mortality  from  tuberculosis 
during  recent  years.  He  says:  "Many  have  connected  the  decrease 
in  the  tuberculosis  mortality  with  the  discovery  of  the  tubercle  bacillus. 
It  was  stated  that  after  the  proofs  have  been  produced  that  tubercu- 
losis is  transmissible,  greater  care  has  been  taken  to  prevent  infection, 
while  before  the  discovery  of  the  tubercle  bacillus  physicians,  and 
with  them  the  laity,  denied  the  transmissibility  of  the  disease.  This 
assumption  surely  has  something  in  its  favor.  At  any  rate,  it  is  a  strik- 
ing fact  that,  with  but  few  exceptions  the  decline  in  the  mortality 
began  a  few  years  after  the  discovery  of  this  bacillus.  But  just  these 
exceptions  prove  that  the  newly  engendered  fear  of  the  dangers  of 
infection  is  not  the  only  factor  operative  in  this  direction,  although 
we  must  give  it  a  certain,  and  not  an  inconsiderable,  amount  of  credit. 
Among  German  authors  we  often  meet  with  the  view  that  the  recent 
social  legislation,  especially  that  concerning  workmen's  insurance,  has 
been  effective  in  reducing  the  tuberculosis  mortality.  To  a  certain 
degree  there  is  some  correlation  in  time  between  these  two  phenomena 
in  Germany.  But,  inasmuch  as  in  most  other  countries  such  laws 
have  not  been  inaugurated  and  the  decline  in  the  tuberculosis  mor- 
tality has  taken  place  to  the  same  extent  as  in  Germany,  this  factor 
should  also  not  be  taken  as  a  cause." 

In  this  country  we  now  hear  similar  opinions  expressed.  William 
Charles  White^  says:  "We  cannot  possibly  avoid  the  facts  that  in 
spite  of  all  our  labor  our  results  are  not  what  we  might  have  expected 
on  a  right  premise;  for  our  reduction  in  morbidity  and  mortality 
from  tuberculosis  has  not  kept  pace  with  the  reduction  in  the  general 
death-rate;  and,  further,  our  reduction  in  mortality  was  about  as  great 

1  Zeitschrift  fiir  Hygiene,  1910,  Ixvii,  1. 

2  Trans.  Nat.  Assn.  Study  and  Prev.  of  Tuber.,  1913,  ix,  80. 


74  THE  EPIDEMIOLOGY  OF   TUBERCULOSIS 

before  we  started  our  present  methods,  and  in.  proving  how  great 
the  influence  of  our  efforts  has  been  we  usually  neglect  all  the  influ- 
ences that  operated  before  we  began,  and  new  factors,  such  as  the 
Mills-Reinecke  phenomenon,  and  ascribe  all  good  to  our  o^aii  work." 

Real  Causes  of  the  Decline  in  the  Tuberculosis  Mortality. — Careful 
study  of  the  economic  and  social  conditions  in  the  various  countries 
where  statistical  data  are  available  shows  clearly  that  there  is  a  pro- 
nounced correlation  between  urbanization,  i.  e.,  concentration  of  large 
masses  of  population  in  cities,  and  the  death-rates  from  phthisis. 
Wherever  the  process  of  urbanization  is  new,  wherever  modern  indus- 
tries have  only  recently  been  introduced,  and  large  numbers  of  rural 
population  have  been  attracted  to  cities,  the  death-rates  from  phthisis 
have  been  rising.  This  is  the  case  in  Japan,  Norway,  Ireland,  Serbia, 
Bulgaria,  etc.,  and  to  a  certain  extent  in  Russia,  Austria,  Italy,  France, 
etc.,  where  the  mortality  has  not  decreased  perceptibly.  On  the  other 
hand,  in  England,  where  industrial  development  was  operative  in 
the  beginning  of  the  nineteenth  century,  it  was  at  that  time  that 
the  high  phthisis  mortality  occurred  and  it  began  to  decline  with  the 
adaptation  of  the  people  to  city  life.  For  this  reason  the  negroes  in 
the  cities  in  the  United  States,  though  having  a  high  phthisis  mor- 
tality, and  no  special  measures  are  taken  to  prevent  dissemination  of 
the  disease  among  them,  also  show  a  strong  tendency  toward  a 
reduction  in  the  death-rates.  Thus,  in  Baltimore,  John  W.  Fulton 
found  to  his  amazement  that  "  both  races  gained  against  tuberculosis, 
the  whites  at  the  rate  of  30.8  per  cent.,  and  the  negroes  at  the  rate  of 
24.5  per  cent,  in  the  decade  of  1904-1913." 

We  have  already  shown  that  whenever  people  who  have  hitherto 
been  free  from  tuberculosis  meet  with  tubercle-laden  surroundings, 
they  succumb  to  the  more  acute  and  fatal  forms  of  the  disease,  while 
most  of  those  who  have  for  generations  been  tuberculized  are  either 
not  harmed  by  infection  at  all,  phthisis  not  developing  after  the  vast 
majority  of  infections,  or  when  it  does  develop,  it  manifests  a  tendency 
to  pursue  an  exceedingly  chronic  course,  or  heals  spontaneously  in  a 
large  number  of  cases.  The  reasons  for  this  phenomenon  will  be  dis- 
cussed under  the  heading  of  Phthisiogenesis  (see  Chapter  V). 

The  decline  in  the  mortality  cannot  be  attributed  to  any  single  cause, 
but  is  apparently  due  to  many  and  complex  factors,  most  of  which 
are  obscure  at  the  present  state  of  our  knowledge.  It  seems,  however, 
that  recent  improvements  in  the  social  and  economic  conditions  of  the 
working  classes,  the  inauguration  of  general  hygienic  and  sanitary 
measures,  and  above  all  the  improvement  in  the  housing  conditions 
and  in  the  quantity  and  quality  of  the  food  consumed  by  the  workmg 
classes,  who  are  the  main  candidates  for  consumption,  have  all  been 
of  assistance  in  this  direction,  although  the  adaptation  of  the  organism 
to  city  life,  and  to  the  tubercle  bacillus,  is  perhaps  of  greater  importance 
than  all  other  factors  taken  together.  We  must  never  forget  in  this 
connection  that  the  modern  methods  of  prevention  aim  at  but  one  thing: 


REAL  CAUSES  OF  DECLINE  IN  TUBERCULOSIS  MORTALITY     75 

the  prevention  of  infection.  And  in  this  they  have  utterly  failed,  as 
they  should  if  we  consider  that  hardly  5  per  cent,  of  the  open  cases 
of  tuberculosis  have  been  isolated.  There  could  not  have  been  more 
than  90  per  cent,  of  humanity  with  tuberculous  lesions  in  their  bodies 
as  we  find  at  present  while  making  autopsies;  there  could  not  have 
been  at  any  time  many  more  than  75  per  cent,  of  humanity  in  cities 
showing  conclusive  evidence  of  having  been  infected  with  tubercle 
bacilli  when  tested  with  tuberculin.  But  what  has  been  achieved  is 
a  reduction  in  the  morbidity,  and  especially  in  the  mortality  from 
phthisis  even  in  those  who,  despite  all  our  efforts  at  prevention,  have 
been  infected  with  the  virus. 


CHAPTER  IV. 

FACTORS  PREDISPOSING  TO  THE  EVOLUTION  OF 

PHTHISIS. 

We  have  seen  that  tuberculosis  is  a  highly  transmissible  disease; 
that  bacteriological,  pathological,  and  clinical  evidence  combine  to 
prove  that  hardly  anybody  exposed  to  tubercle  bacilli  escapes  infec- 
tion. The  only  difference  of  opinion  among  authorities  at  present 
appears  to  be  whether  as  many  as  95  per  cent,  of  civilized  humanity 
show  evidence  that  the  tubercle  bacilli  have  been  implanted  in  some 
organs  of  their  bodies,  or  merely  70  per  cent.  It  is  now  important  to 
inquire  why  only  10  or  12  per  cent,  of  hiunanity  succumb  to  this 
disease  while  nearly  90  per  cent,  remain  in  good  health,  in  spite  of 
tuberculous  infection  of  which  they  show  undoubted  traces.  "If, 
of  a  large  number  of  persons  exposed,"  says  Kingston  Fowler,  "to 
infection  and  mfected,  only  a  few  acquire  the  disease,  the  suscep- 
tibility becomes  a  factor  in  causation  of  greater  moment  than  exposure 
to  infection." 

Tuberculosis  is  not  a  clinical  entity  like  typhoid  fever,  pneumonia, 
or  smallpox,  running  a  certain  course,  at  times  severe,  often  mild, 
but  always  producing  the  same  clinical  picture.  Tuberculosis  in 
children  produces  a  dift'erent  clinical  picture  than  in  adults.  In  the 
former  it  is  usually  a  bacteremia,  aft'ecting  the  glands,  bones,  joints, 
etc.,  while  in  the  latter  it  is  a  local  chronic  disease  of  the  lungs — 95 
per  cent,  of  tuberculosis  in  adults  is  phthisis  pulmonum.  How  are 
these  phenomena  to  be  explained?  Even  the  evidence  which  tends 
to  show  that  milk  from  tuberculous  cattle  is  responsible  for  the  mild 
forms  of  tuberculosis  in  children,  while  the  human  type  of  bacilli  is 
responsible  for  the  phthisis  in  adults  and  the  graver  forms  in  children, 
is  insufficient  to  explain  all  these  remarkable  phenomena.  The  fact 
that  adults  consume  the  same  milk  is,  among  others,  proof  that  there 
are  other  factors  operative  in  phthisiogenesis. 

Another  important  problem  in  phthisiogenesis  is  why  do  those 
affected  with  tuberculosis  of  the  lungs  show  such  different  proclivities 
to  suffer  as  a  result  of  infection  with  the  same  type  of  bacillus  V  Clinic- 
ally, we  find  that  some  are  attacked  with  the  acute  forms  of  the  disease, 
such  as  acute,  general  miliary  tuberculosis,  acute  pneumonic  phthisis, 
etc.,  and  succumb  in  a  relatively  short  time;  others  suffer  from  sub- 
acute phthisis,  which  may  progress  slowly  or  rapidly  to  a  fatal  termina- 
tion, or  suddenly  take  a  turn  for  the  better  and  run  a  chronic  course 
without  any  apparent  reason  to  account  for  the  change  in  tlie  nialig- 


HEREDITY  77 

nancy  of  the  disease;  in  still  others  the  disease  begins  insidiously, 
runs  a  slow,  sluggish  course  for  many  years,  incapacitating  the  patient 
now  and  then  for  a  variable  period,  yet  he  lives  indefinitely,  perhaps 
his  natural  life,  and  may  die  from  some  intercurrent  disease.  To 
these  must  be  added  the  large,  in  fact  the  enormous,  number 
of  persons  in  whom  the  implantation  of  the  tubercle  bacilli  in  the 
lungs,  or  any  other  organ,  produces  anatomical  changes  in  structure 
unmistakably  recognizable  at  the  necropsy;  yet  these  lesions  heal 
spontaneously,  the  patient  and  his  physician  knowing  nothing  about 
the  morbid  phenomena  of  tuberculosis  during  the  life  of  the  individual. 

What  are  the  factors  which  endow  this  last  class  of  persons,  who 
are  in  the  majority  among  the  living,  with  resisting  power  that  the 
implantation  of  tubercle  bacilli  in  their  bodies,  even  causing  structural 
changes  in  their  lungs,  does  not  in  the  least  affect  their  general  health? 
Which  are  the  factors  that  predispose  others  so  that  when  the  bacilli 
are  implanted  in  their  bodies  the  disease  runs  an  acute  or  subacute 
course  and  they  sooner  or  later  succumb  to  the  action  of  these  micro- 
organisms and  their  toxins? 

Theories  of  Predisposition. — Various  answers  have  been  given  to 
these  questions. 

1.  Some  have  seen  in  the  predisposition  of  patients  an  expression 
of  heredity;  that  there  are  families  who  are  exceedingly  predisposed 
to  the  action  of  the  tubercle  bacilli,  while  others  possess  more  or  less 
resistance  in  this  regard.  In  -the  former  infection  is  followed  by 
phthisis,  or  tuberculosis  of  some  other  organs,  which  may  be  mild  or 
severe;  while  in  the  latter  infection  is  merely  followed  by  a  change 
in  the  biological  properties  of  the  blood  as  can  be  seen  from  their 
altered  reactivity  to  tuberculin. 

2.  Others  have  attributed  the  predisposition  to  phthisis  to  con- 
stitutional, biochemical  or  serological  derangements  of  the  body  or 
the  blood.  There  have  even  been  suggested  methods  of  treatment 
of  the  disease  along  the  lines  of  removing  the  constitutional  defects 
and  thus  preventing  or  curing  the  disease. 

3.  Finally,  others  have  maintained  that  the  predisposition  to  phthisis 
depends  on  certain  local  anatomical  peculiarities  of  the  lungs  or  the 
thoracic  skeleton  which  reduce  the  vitality  of  the  organ  and  thus 
favor  the  proliferation  of  the  bacilli  which  may  have  been  brought 
there  by  the  air  or  circulating  blood. 

We  shall  discuss  these  theories  in  some  detail. 


HEREDITY. 

Lack  of  Reliable  Statistics  on  Heredity  of  Phthisis. — The  theory 
of  hereditary  predisposition  may  be  supported  by  either  statistical 
data  about  ancestral  tuberculosis,  or  by  biological  observations  in 
diseased  organisms. 


78      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

For  centuries  physicians  have  noted  that  in  certain  famiHes  tuber- 
culosis reappears  in  successive  generations,  and  many  patients  can 
trace  the  disease  back  to  their  ancestors  and  blood  relatives.  Statistics 
collected  along  these  lines  are  plentiful,  but  on  close  analysis  it  appears 
that  they  are  of  little  value  in  proving  or  disproving  the  hereditary 
transmission  of  the  disease,  or  of  a  predisposition  to  it. 

Even  disregarding  the  ubiquity  of  the  disease,  one  out  of  every 
seven  or  eight  deaths  is  due  to  it,  so  that  it  may  be  found  in  any 
large  family  or  its  branches,  it  must  be  borne  in  mind  that  the  average 
history  of  a  tuberculous  patient  who  is  derived  from  uneducated 
social  classes  is  very  unreliable.  The  statements  about  the  state 
of  health,  and  especially  the  causes  of  death  of  grandparents,  parents, 
brothers  and  sisters  are  open  to  criticism  in  the  vast  majority  of  cases. 
Even  the  questions  about  their  personal  history  are  not  accurately 
answered  as  a  rule.  Our  patients  at  the  Montefiore  Home  nearly 
all  state  that  they  had  measles  during  childhood,  probably  on  the 
principle  that  everj^one  must  have  it.  But  very  few  say  that  they 
have  had  diphtheria,  typhoid,  typhus,  scarlet  fever,  etc.,  although 
most  of  them  come  from  eastern  Europe  where  these  diseases  are 
rampant  and  hardly  any  attempts  are  made  to  check  them  by  proper 
quarantine  regulations,  and  very  few  indeed  escape.  Very  few  know 
the  cause  of  death  of  their  parents,  hardly  any  that  of  their  grand- 
parents; in  fact  it  would  seem  as  if  their  parents  were  all  immune  to 
phthisis,  considering  that  the  patients  do  not  mention  it  after  questions 
are  addressed  to  them  on  the  subject. 

In  private  practice,  where  we  deal  with  a  more  intelligent  class,  we 
often  find  that  the  father  has  coughed,  the  mother  had  hemoptysis,  etc., 
after  a  categorical  answer  that  there  has  been  no  consumption  in  the 
family.  On  the  other  hand,  we  know  how  much  suggestion  through 
leading  questions  suitable  for  a  certain  theory  may  bring  out  appro- 
priate answers.  Many  patients  are  convinced  that  their  blood  is  not 
by  any  means  "tainted,"  that  they  "come  from  healthy  stock,"  that 
"there  has  never  been  any  consumption  in  their  family,"  etc. 

To  prove  statistically  the  hereditary  transmission  of  tuberculosis, 
or  a  predisposition  to  the  disease,  carefully  kept  records  of  many 
families  would  be  required,  in  which  children  of  tuberculous  parentage 
have  succumbed  to  the  disease  despite  the  fact  that  they  have  been 
removed  immediately  after  birth,  thus  preventing  exposure  to  infec- 
tion through  intimate  contact.  This  we  do  not  have.  Even  the  data 
given  by  orphan  asylums,  showing  that  thousands  of  children  of 
tuberculous  parentage  do  not  develop  tuberculosis,  are  of  absolutely 
no  value  in  disproving  heredity  of  this  disease.  In  thesejinstitutions 
children  under  fourteen  are  usually  kept,  and  at  thatjage'active'phthisis 
is  exceedingly  rare,  as  has  already  been  shown. 

For  these  reasons  very  little  confidence  can  be  })lace(l  in  the  statis- 
tical compilations  of  various  authors  to  the  effect  that  among  their 
patients  25,  44.7,  or  59.2  per  cent,  have  given  a  history  of  tuberculosis 


GERMINATIVE  TRANSMISSION  79 

in  the  parents,  grandparents,  brothers,  sisters,  or  collaterals.  It  de- 
pends a  great  deal  on  the  zeal  of  the  questioner  to  obtain  points  for 
the  substantiation  of  his  pet  theory.  Even  the  excellent  statistical 
studies  of  Karl  Pearson,  Weinberg,  Schliiter  and  many  others  are  not 
at  all  convincing.  In  fact  M.  Burckhardt^  has  found  that  in  non- 
tuberculous  persons  tuberculosis  in  ascendency  is  just  as  strongly 
represented  as  in  the  tuberculous,  and  that  the  disease  in  the  father  is 
just  as  frequent  in  both  groups,  while  the  frequent  occurrences  in  the 
mothers,  fathers,  brothers,  sisters,  uncles,  and  aunts  can  easily  be 
explained  by  infection. 

Germinative  Transmission. — ^The  reappearance  of  tuberculosis  in 
several  successive  generations  is  by  no  means  proof  that  the  disease 
has  been  transmitted  by  heredity,  nor  even  that  the  so-called  predis- 
position to  the  disease  has  been  inherited.  In  coal  miners  the  lungs 
show  changes  of  anthracosis  through  several  generations,  so  long  as 
they  are  engaged  at  that  occupation.  But  no  one  will  say  that  it  has 
been  inherited.  Similarly,  the  social,  economic,  hygienic,  and  sani- 
tary conditions  and  surroundings  which  were  responsible  for  the 
phthisis  in  the  parents  may  be,  and  usually  are,  operative  in  the 
children  who  remain  in  the  same  social  milieu.  We  may  justly  speak 
of  social  heredity,  but  not  of  biological  heredity.  The  latter  implied 
the  transmission  of  characters  or  their  physical  foundation,  which 
were  contained  in  the  germ  plasm,  or  the  parental  sex  cells.  Anything 
that  may  affect  the  fertilized  ovum,  or  affect  the  embryo,  cannot  be 
considered  inherited,  as  was  pointed  out  by  Martius,^  who  also  shows 
that  intra-uterine  infection  and  germinative  transmission  of  a  disease 
have  nothing  to  do  with  the  problems  of  heredity,  just  as  extra-uterine 
influences  cannot  be  considered  transmissible. 

Experimental  investigations  by  Friedmann  show  that  intra-uterine 
infection  with  tubercle  bacilli  is  not  impossible.  This,  in  some 
measure,  confirms  Baumgarten's  theory  to  the  effect  that  tubercle 
bacilli  may  enter  the  blood  stream  of  the  fetus,  remain  dormant  for 
a  long  period  of  years,  to  flare  up  again  by  intense  multiplication  when 
for  some  reason  the  natural  resistance  of  the  body  fails.  This  form 
of  transmission  of  phthisis  cannot  strictly  be  considered  germinative 
heredity — it  is  actually  infection  of  the  fetus  from  the  mother — yet 
it  is  important  for  the  clinician,  especially  to  one  giving  thought  to 
prophylaxis. 

Baumgarten^  bases  his  theory  mainly  on  experiments  with  tuber- 
culous chickens.  It  is  well  known  that  the  progeny  of  tuberculous 
chickens  is  tuberculous  even  under  conditions  when  infection  after 
the  egg  has  been  laid  can  be  positively  excluded.  Experimentally 
it  has  been  found  that  the  albumen  of  a  fertilized  egg  may  be  inocu- 
lated with  tubercle  bacilli,  and  the  evolution  of  the  chick  goes  on  as 

•  Zeitschr.  f.  Tuberkulose,   1904,  v,  29. 

2  In  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  der  Tuberkulose,  1914,  i,  395. 

3Arb.  a.  d.  Gebiet.  d.  Path.  Anatom.  u.  Bakteriol.,  1891-1892,  vol.  i. 


80      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

usual;  but  it  develops  tuberculosis  after  it  is  hatched.  This  has  been 
done  by  Baumgarten,  Milchner,  Gartner,  Maffucci,  Koch,  and  others. 
The  germinative  or  placental  transmission  of  tuberculosis  in  which  the 
female  ovum,  or  the  male  cell,  or  the  complete  embryo  is  infected 
through  the  placental  circulation  with  tubercle  bacilli,  yet  keeps  on 
developing,  has  been  proved  by  other  observations,  notably  in  cases 
in  which  the  newborn  infant  was  found  tuberculous.  Many  such 
cases  have  been  reported  during  recent  years  as  occurring  in  cattle 
and  also  in  human  beings.  In  fact,  localized,  calcareous  degeneration 
of  some  focus  in  the  lungs  has  been  found  in  newborn  infants,  showing 
that  they  had  tuberculosis  in  utero  and  that  the  lesions  healed. 

We  are  in  the  dark  as  to  how  these  bacilli  reached  the  embryo.  There 
are  proofs  that  the  female  ovum  may  be  infected  with  tubercle  bacilli. 
Westerme^'er,  Jani,  Jackh,  and  others  have  found  tubercle  bacilli  in 
the  human  ovary  and  Spano,  Porter,  Friedmann,  and  others  have 
found  them  in  the  semen.  To  be  sure,  these  findings  were  mostly  in 
persons  dead  from  acute  miliary  tuberculosis,  but  it  must  be  borne 
in  mind  that  individuals  with  genital  tuberculosis  often  cohabit  with 
the  opposite  sex  and  pregnancy  is  frequent.  Indeed,  Albrecht,  Cav- 
agnis,  Maffucci,  and  others  have  succeeded  in  infecting  rabbits  and 
guinea-pigs  with  semen  taken  from  bulls  suffering  from  tuberculosis. 
Friedmann^  injected  an  emulsion  of  tubercle  bacilli  into  the  vagina 
of  rabbits  immediately  after  they  had  been  impregnated  by  the  male. 
Subsequent  observation  showed  that  while  the  mothers  remained  free 
from  disease,  tubercle  bacilli  were  found  in  sparing  numbers  in  the 
seven-day-old  fetuses,  which  were  not  at  all  hampered  in  their  evolu- 
tion. In  newborn  rabbits  whose  mothers  were  thus  treated,  tubercle 
bacilli  were  found  in  various  organs.  This  tends  to  prove  that 
spermatogenic  infection — i.  e.,  infection  with  tubercle  bacilli  brought 
along  with  the  semen  from  a  tuberculous  father — is  possible. 

But,  as  has  been  pointed  out  by  Romer,^  it  can  be  stated  that  in 
general  semen  contains  tubercle  bacilli  only  when  the  genital  organs, 
especially  the  testicles,  are  affected.  There  is,  however,  no  doubt  that 
genital  tuberculosis  in  the  male  may  be  transmitted  to  the  oft'spring. 
But  it  should  be  emphasized  that  this  must  be  of  exceedingly  rare 
occurrence  considering  that  with  each  emission  millions  of  sperma- 
tozoa are  expelled,  and  that  the  one  on  which  a  bacillus  has  implanted 
itself  should  be  just  the  one  that  fertilizes  the  ovum,  is  a  rather  remote 
chance.  This  mode  of  infecting  the  ovum  may  therefore  be  left  out  of 
consideration. 

In  fact,  Romer,^  carefully  analyzing  the  results  of  this  and  other 
experimental  work  along  these  lines,  arrives  at  the  conclusion  that  so 
far  no  unequivocal  proof  is  available  in  favor  of  the  possibility  of 
infection  of  the  spermatozoa  which   should  remain  with   sufficient 

1  Zeitschr.  f.  kliii.  Med.,  V.H)\,  Iviii,  2. 

2  In  Braucr,  .Schroder,  and  Hlunicnfeld'y  Handhucli  d.  TulKTkulo.sc,  l'.)14,  i,  272. 

3  Ibid.,  p.  274. 


PLACENTAL  TRANSMISSION  81 

vitality  to  impregnate  the  ovum,  and  a  tuberculous,  yet  living,  infant 
should  be  born  and  continue  alive  for  some  time. 

Placental  Transmission. — But  there  is  another  possibility,  namely, 
intra-uterine  infection  of  the  healthy  fetus  from  a  phthisical  mother 
during  pregnancy ;  the  tubercle  bacilli  entering  by  way  of  the  placental 
circulation.  That  the  placenta  may  harbor  tubercle  bacilli  is  well 
known;  the  frequent  bacteremia  in  phthisis  explains  it.  Lehmann, 
Runge,  Nowack,  Auche,  Chamberland,  and  many  others  have  found 
tubercle  bacilli  in  the  human  placenta.  On  carefully  examining  the 
histology  of  the  placenta  of  phthisical  pregnant  women,  Schmorl 
and  Geipe^  found  tubercle  bacilli  in  9  out  of  20  cases.  In  1  of  the 
9  the  mother  had  merely  an  incipient  apical  lesion.  Schmorl  estimates 
that  50  per  cent,  of  pregnant  phthisical  women  have  tubercle  bacilli 
in  their  placentas.  He  maintains  that  tubercle  bacilli  may  enter 
the  placenta  during  any  period  of  pregnancy,  and  in  any  stage  of  the 
disease,  but  that  they  are  mostly  found  in  the  advanced  stages  of 
phthisis  and  in  acute  miliary  tuberculosis.  The  fetus  may  be  infected 
from  the  mother  during  the  act  of  birth  when  vigorous  contractions 
of  the  uterus  may  lacerate  some  of  the  less  resisting  parts  of  the 
placenta.  Infection  of  the  fetus  may  also  occur  earlier.  That  they 
should  enter  directly  into  the  fetus  is  a  remote  probability,  if  at  all 
possible,  but  the  bacilli  may  be  brought  to  the  fetus  by  the  blood 
through  the  umbilical  vein;  or  by  way  of  the  intestine  after  they 
have  reached  the  amnionic  fluid  and  were  then  swallowed  or  aspirated 
be  the  fetus.  There  have  been  found  tubercle  bacilli  in  the  organs  of 
newborn  infants  which  showed  no  macroscopic  or  microscopic  tuber- 
culous changes. 

But  very  few  cases  of  congenital  tuberculosis  have  been  found 
despite  the  fact  that  they  have  been  carefully  looked  for.  Pehu  and 
Chalier^  found  only  51  authentic  cases  on  record  in  medical  literature. 
It  may  be  added  that  most  of  the  cases  were  not  conclusively  proved. 
Romer^  knows  of  but  30  cases  and  some  of  them  may  be  said  to  be 
reliable  only  "in  all  probabilities."  Pehu  and  Chalier  believe  that 
in  these  cases  infection  usually  takes  place  at  the  end  of  pregnancy 
when  the  placental  circulation  is  established  and  results  from  a  bac- 
teriemia  which  is  usually  a  terminal  event.  They  should  therefore  be 
regarded  as  examples  of  transplacental  heredocontagion  and  not  of 
direct  heredity. 

It  is  thus  shown  that,  theoretically,  placental  transmission  of  tuber- 
culosis is  possible.  But  all  available  facts  combine  to  prove  that  it 
is  exceedingly  rare  among  human  beings.  Indeed,  when  compared 
with  the  large  number  of  infections  after  birth,  the  few  recorded  cases 
of  congenital  tuberculosis  sink  into  insignificance.  After  all,  when  it 
does  occur  at  all,  it  is  from  mothers  who  are  in  the  far-advanced 
stages  of  phthisis,  or  who  have  tuberculous  disease  of  the  genito- 

1  Ziegler's  Beitrage,  ix,  428;    Miinch.  med.  Wchnschr.,  1904,  p.  1070. 

2  Arch,  de  Med.  de.s  enfants,  1914,  xvii,  721.  ^  Loc.  eit.,  p.  27(3. 

6 


82      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

urinary  system.  Such  women  only  rarely  conceive,  and  when  they 
do,  abortion  is  the  rule.  It  is  a  fact  worthy  of  note  in  this  connec- 
tion that  numerous  examinations  of  stillborn  fetuses  from  phthisical 
mothers  have  not  revealed  any  traces  of  tuberculous  infection;  even 
inoculation  experiments  have  failed. 

Among  cattle  congenital  tuberculosis  appears  to  be  more  frequent 
than  among  humans.  Still,  the  application  of  the  well-known  Bang 
system  has  shown  that  even  here  it  is  exceedingly  rare.  In  the  United 
States  Harlow  Brooks^^  has  shown  that  when  calves  are  removed  from 
their  tuberculous  mothers  immediately  after  birth,  they  do  not  develop 
the  disease. 

Clinical  Facts  of  Heredity. — Many  authors  have  observed  certain 
clinical  phenomena  which  cannot  be  explained  otherwise  than  by 
heredity,  either  of  the  disease  or  of  a  predisposition  to  it.  Brehmer, 
and  after  him  several  other  writers,  found  that  in  many  cases  the 
onset  of  the  disease  occurs  at  the  same  age  in  parents  and  children. 
Fiery  found  that  in  many  families  the  children  mostly  succumb  before 
attaining  the  age  of  sixteen.  While  many  cases  can  be  cited  in  sub- 
stantiation of  these  observations,  it  appears  that  so  far  a  sufficient 
number  has  not  been  collated  to  prove  their  significance  conclusively. 

Of  greater  moment  is  the  inheritance  of  the  locus  minor  is  resistentioB, 
which  Brehmer  described  long  ago  and  Turban,^  Baldwin,^  Moeller, 
Kuthy,*  and  others  have  confirmed.  It  appears  that  when  pulmonary 
tuberculosis  occurs  in  parents  and  children,  the  chances  are  immense 
that  the  same  side  of  the  chest  should  be  affected  in  each  case.  This 
family  resemblance  in  phthisis  has  been  found  in  about  75  per  cent, 
of  cases.  In  my  own  experience  I  also  observed  that  in  about  two-thirds 
of  cases  the  side  affected  was  the  same  in  the  several  affected  members 
of  the  family.  Moeller^  points  out  that  when  a  child  suffers  from  a 
tuberculous  lesion  of  some  bone,  the  chances  are  that  when  its  brother 
or  sister  develops  tuberculosis  it  will  also  be  a  disease  of  bone  and 
not  of  the  soft  tissues.  These  facts  are  explained  by  the  assumption 
that  some  organs  or  tissues  in  the  body  lack  powers  of  resistance,  and 
that  this  defect  is  transmitted  by  heredity.  This  will  be  discussed 
again  when  speaking  of  the  thoracic  anomalies  and  their  relation  to 
phthisiogenesis.  Meanwhile  it  may  be  stated  that  these  problems 
have  not  received  the  careful  study  they  deserve. 

Disturbances  in  the  Metabolism  as  Predisposing  Factors. — In  the 
search  for  the  factors  predisposing  to  phthisis  many  have  looked  into 
the  metabolism  of  the  body,  stating  that  tuberculous  infection  is 
harmless  in  the  vast  majority  of  persons,  as  long  as  the  metabolic 
processes  are  normal;  only  when  certain  disturbances  occur  in  this 
regard  can  phthisis  develop.     Some  excellent  investigations  into  the 

1  Amor.  Jour.  Med.  Sci.,  1914,  c.xlviii,  "IS;  Tnins.  Soc.  Exper.  Med.  and  Biol.,  1914, 
xi,  50. 

2  Zeitsehr.  f.  Tuberk.,  1900,  i,  30.  ^  Yale  Mod.  Jour.,  1902,  p.  215. 
*  Zeitsehr.  f.  Tuberk.,  1913,  xx,  3S. 

'Lehrbuch  d.  Lungcntuberkulose,  Berlin,  1910,  p.  30. 


ANATOMICAL  PECULIARITIES  PREDISPOSING  TO  PHTHISIS     83 

functions  of  the  internal  secretion  of  the  ductless  glands  have  brought 
no  positive  results  so  far.  At  any  rate,  we  do  not  know  at  present  that 
disturbances  in  the  structure  or  functions  of  the  thyroid,  pituitary,  or 
suprarenal  glands  have  an  influence  in  enhancing  the  growth  of  tubercle 
bacilli  in  the  body.  It  is^  however,  a  fact  that  in  the  enormous  litera- 
ture on  the  subject  of  tuberculosis,  we  cannot  find  an  exhaustive 
study  of  the  metabolism  of  persons  affected  with  the  disease,  and 
hardly  anything  about  the  metabolism  in  the  so-called  pretuberculous 
stage. 

Several  authors  have  maintained  that  an  excessive  excretion  of  cal- 
cium in  the  urine  can  be  found  in  all  cases  of  phthisis  long  before  the 
onset  of  the  disease.  In  this  country  Croftan,^  Russell,  and  others  have 
made  some  studies  along  these  lines,  and  several  French  authors — 
Robin,2  Binet,  etc. — have  found  that  in  the  pretuberculous  stage  there 
is  a  pronounced  excess  in  the  excretion  of  inorganic  salts  in  the  urine, 
notably  those  of  lime  and  magnesia.  The  result  is  that  the  blood, 
bones,  and  lung  tissues  show  a  distinct  lack  in  these  mineral  salts. 
Gaube  found  that  the  descendants  of  phthisical  subjects  excrete  on 
the  average  more  calcium  and  magnesia  than  those  of  healthy  stock. 
Robin  sees  in  this  lime  and  magnesia  starvation  an  excessive  amount 
of  self-combustion,  and  he  considers  this  anomaly  in  the  metabolism 
the  main  element  in  the  preparation  of  the  soil  prone  to  tuberculosis, 
whatever  the  remote  cause  may  be — heredity,  alcoholism,  malnutri- 
tion, overwork,  etc.  Infection  alone  is  insufficient  to  produce  phthisis, 
as  is  evident  from  the  fact  that  most  people  infected  with  tubercle  bacilli 
escape  the  disease.  It  is  only  when  the  soil  is  prepared  by  the  dis- 
similation and  emaciation,  by  pretuberculous  decay,  as  Robin  calls 
it,  that  phthisis  may  develop.  The  gravity  of  the  pulmonary  lesion 
goes  hand-in-hand  with  the  degree  of  lime  starvation,  demineral- 
ization  and  emaciation  of  the  body.  According  to  these  writers, 
phthisis  is  preventable.  Demineralization  of  the  body  must  be  sought 
and,  when  discovered,  prevented  by  the  administration  of  remedies 
tending  to  replace  the  lime  and  magnesium  which  are  being  eliminated 
from  the  body  excessively. 

These  and  other  findings  about  the  metabolism  in  phthisis  have 
not  been  confirmed  by  all  who  have  made  careful  studies  along  these 
lines.  It  appears  that  in  the  vast  majority  of  consumptives  the  metab- 
olism is  quite  normal  as  long  as  there  is  no  high  fever.  The  occasional 
lapses  in  the  metabolism  are  explained  by  the  usual  causes  of  morbid 
phenomena  observed  in  other  diseases  characterized  by  fever,  emacia- 
tion, debility,  etc.  At  any  rate,  this  subject  has  not  been  studied 
sufficiently  to  permit  making  generalizations. 

Anatomical  Peculiarities  Predisposing  to  Phthisis.— The  hereditary 
and  constitutional  factors  discussed  above  may  explain  some  of  the 
phenomena  of  tuberculous  disease,  but  they  fail  to  give  an  adequate 

1  Sixth  Intern.  Cong.  Tuber.,  1908,  i,  275. 

2  Traitement  de  la  tuberculosa,  Paris,  1912. 


84      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

explanation  for  all  the  cases  of  phthisis  which  are  met  with  in  practice. 
For  these  reasons  many  authors  have  suggested  that  local  and  anatom- 
ical peculiarities  are  responsible  for  the  liability  of  the  lung  apex  to 
tuberculous  degeneration. 

Various  hypotheses  have  been  promulgated  with  a  view  of  explain- 
ing why  phthisis  is  localized  in  nearly  all  cases  in  adults  in  the  apices 
of  the  lungs.  Some  have  suggested  that  the  determining  factor 
is  the  blood  content  of  these  organs.  It  is  shown  that  in  congenital 
heart  disease,  pulmonary  stenosis,  which  is  characterized  by  oligemia 
of  the  lungs,  nearly  all  patients  succumb  to  pulmonary  tuberculosis. 
On  the  other  hand,  in  diseases  of  the  left  heart,  especially  in  mitral 
stenosis,  which  are  characterized  by  hyperemia  of  the  lungs,  phthisis 
is  very  rare.  It  has  also  been  found  that  in  the  upper  parts  of  the 
lungs  the  blood  and  lymph  currents  are  slower  than  in  other  parts, 
and  thus  embolic  deposits  of  bacilli  are  favored,  no  matter  by  which 
channel  they  have  entered.  Calmette's  experimental  investigations 
(see  p.  47)  seem  to  confirm  this  view.  Then  it  must  be  mentioned 
that  the  uppermost  three  ribs  show  lesser  respiratory  excursions  than 
the  lower  ribs.  The  result  is  a  slower  air  current  in  the  upper  part  of 
the  lung  and  foreign  bodies  brought  in  by  the  inspired  air  are  retained 
in  the  apex.  But  these  and  many  other  hypotheses  have  failed  to 
adequately  explain  the  apical  localization  of  phthisis,  especially  now, 
since  we  know  that  infection  takes  place  during  childhood,  while 
the  evolution  of  the  disease  begins  after  maturity  of  the  patient,  as  a 
rule. 

Freund's  Theory  of  Stenosis  of  the  Upper  Thoracic  Aperture. — 
About  fifty  years  ago  Freund"^  pointed  out  that  stenosis  of  the  bony 
thorax  is  very  frequently  encountered  in  consumptives,  but  his  obser- 
vations were  neglected  and  soon  forgotten,  to  be  taken  up  again  by 
himself.  Hart  and  Harras,^  and  others.  Bacmeister's^  experimental 
investigations  have  finally  given  great  plausibility  to  Freund's  theory. 

The  deformity  of  the  upper  thoracic  girdle,  which  may  be  congenital 
or  acquired,  consists  mainly  in  an  ossification  of  the  first  costal  cartilage 
and  a  shortening  of  the  first  rib  which  exerts  pressure  upon  the  lung 
apex  which  it  surrounds,  thus  obstructing  the  circulation  of  the 
blood  and  lymph  and  preventing  the  removal  of  any  foreign  body — 
the  tubercle  bacilli — that  may  be  brought  there  by  the  blood  or  the 
inspired  air,  and  favoring  its  localization  at  this  point.  Shortening  of 
the  first  costal  cartilage  also  involves  an  excessive  inclination  of  the 
upper  thoracic  aperture  toward  the  spinal  column.  The  sternum  lies 
too  deeply,  the  ribs  run  slantingly  downward,  the  shoulders  hang  low 
and  forward,  the  scapulae  protrude  like  wings,  and  the  result  is  the 
phthisical  chest  of  the  classical  authors. 

Freund,  Hart,  and  Harras  have  studied   the  tuberculous  thorax 

1  Beitr.  z.  Histologie  d.  Rippenknorpel,  Breslau,  1858. 

2  Der  Thorax  phthisicus,  Stuttgart,  1908. 

3-Die  Entstchung  der  mcnschlichen  Lungenplithisi',  Berlin,  1U14. 


FREUND\S  THEORY  OF  STENOSIS  OF  THORACIC  APERTURE     85 

on  the  autopsy  table  and  in  the  Hvmg  with  the  aid  of  radiography, 
and  have  found  that  stenosis  of  the  upper  aperture  is  very  frequent. 
The  abnormal  shortening  of  the  first  rib  makes  the  transverse  diameter 
short,  converting  the  human  thorax  into  one  like  that  of  the  lower 


Fig.  4. — Diagrammatic  representation  of  the  upper  aperture  of  the  thorax:  a,  the 
primary  form  (animals,  primitive  human  form);  b,  secondary  form  (adult  man).  (After 
Wiedersheim.) 

animals,  and  to  a  certain  extent  infantile,  as  is  shown  in  Fig.  4. 
The  narrowing  usually  occurs  at  the  lateroposterior  bulging,  exactly 
where  the  apices  of  the  lung  are  surrounded  by  the  first  rib,  which 
under  these  conditions  compresses  the  pulmonary  tissues  beneath. 
This  deformity  may  occur  unilaterally  or  bilaterally,  but  the  end- 


FiG_  5_ — Upper  aperture  of  the  thorax:     A,  normal  on  left  side;    B,  narrowed  at   the 

right.      (Freund.) 

result  is  always  the  same— narrowing  and  rigidity  of  the  upper  thoracic 
girdle  with  resulting  compression  of  the  lung. 

Independent  of  Freund,  SchmorP  found  a  groove  about  2  cm.  below 

1  Miinch.  med.  Wochenschrift,  1902,  xlviii,  1995. 


86      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

the  highest  point  of  the  apex  of  the  hmg.  This  groove  is  very  frequently 
encountered  in  newborn  infants,  but  in  them  it  can  be  obhterated  when 
the  lung  is  inflated.  During  adolescence  it  disappears  in  persons  with 
normal  chest  walls.  In  most  persons  in  whom  it  persisted  Schmorl 
found  tuberculous  lesions  beneath  the  point  which  was  pressed  upon 
by  the  shortened  rib  (Figs.  6  and  7). 

These  observations  have  been  confirmed  by  Birch-Hirschfeld'  from 
another  point  of  view.  While  searching  for  the  initial  lesion  of  tuber- 
culosis in  cadavers  dead  from  other  diseases,  he  found  that  phthisis 


Fic.   6. — Right    lung.     (Hiss's    model.)  Fig.  7. — Left  lung.     The  groove  of  the 

The  indentations    made    by    the    ribs    are         first   rib   is  shallower  than   in    the    right 
shown.   The  first  groove  is  the  indentation         lung, 
made  by  the    first  rib    and  is    known  as 
Schmorl's  groove. 

begins  in  the  walls  of  a  bronchus  of  the  third  to  the  fifth  order,  and 
ascribed  it  to  certain  pressure  exerted  on  these  tubes,  preventing  the 
exit  of  air  and  secretions.  This  bronchiole,  which  Clift'ord  Allbutt 
caUs  "  Hirschfeld's  bronchiole,"  from  its  position  and  nature,  favors 
that  secretions,  instead  of  clearing  themselves  automatically,  will 
stagnate  more  or  less  if  pressed  upon  to  a  greater  or  lesser  degree  by 
the  first  rib,  located  as  it  is  on  the  apex,  leading  spirally  against  the 
action  of  gravitation  upward,  outward,  and  backward. 

'  Deutsches  Arch.  f.  klin.  Medizin,  1899,  Ixiv,  .5S. 


FREUND'S  THEORY  OF  STENOSIS  OF  THORACIC  APERTURE     87 

Finally,  Bacraeister's'  investigations  ha\'e  apparently  confirmed 
these  anatomical,  pathological,  and  clinical  findings.  He  surrounded 
young  and  growing  rabbits,  with  a  wire  loop  at  the  first  costal  ring, 
thus  causing  stenosis  of  the  upper  aperture  of  the  bony  thorax.  The 
pulmonary  apex  was  thus  compressed,  and  a  groove  was  indented  in 
the  lung  beneath  the  wire  loop  corresponding  to  the  one  observed  by 
Schmorl  in  human  consumptives.  Infecting  these  animals,  he  pro- 
duced isolated  and  localized  pulmonary  tuberculosis,  while  in  normal 
animals,  used  as  controls,  infection  produced  miliary  tuberculosis, 
but  never  localized  tuberculosis  of  an  apex.  In  this  manner  he 
could  produce  local  tuberculous  lesions  on  either  side  of  the  chest, 
or  bilaterally. 

There  is  considerable  evidence  in  support  of  this  theory.  In  children 
the  upper  aperture  of  the  thorax  is  very  elastic,  and  therefore  apical 
phthisis  is  exceedingly  rare;  when  infected,  the  tracheobronchial  glands 
are  affected,  or  general  miliary  tuberculosis  is  the  result.  During 
the  period  of  puberty,  when  the  spinal  column  grows  and  raises  the 
upper  thoracic  girdle,  permitting  the  first  rib  to  exert  pressure  on 
the  pulmonary  apex,  typical  phthisis  may  occur.  The  largest  number 
of  cases  of  active  tuberculosis  of  the  lung,  though  not  the  largest  num- 
ber of  deaths  due  to  this  cause,  occur  between  fifteen  and  thirty 
years;  between  thirty  and  forty  the  proportion  diminishes,  and 
between  forty  and  sixty  there  again  occur  a  large  number  of  cases. 
Hart  explains  these  phenomena  in  this  manner:  During  puberty  and 
soon  thereafter  any  congenital  or  acquired  shortening  of  the  first  rib 
becomes  dangerous  to  the  individual  because  the  growing  apex  of 
the  lung  finds  itself  hemmed  in  the  small  thoracic  cavity  and  the 
shortened  first  rib  compresses  it,  thus  favoring  tuberculous  degenera- 
tion. After  forty,  when  ossification  of  the  costal  cartilage  is,  to  a 
certain  extent,  normal,  conditions  are  again  favorable  for  the  develop- 
ment of  phthisis. 

While  several  authors  have  confirmed  Freund's  and  Hart's  findings, 
others,  like  Schulze  and  Smith,  have  looked  for  stenosis  in  the  upper 
aperture  of  the  thorax  while  making  autopsies  on  tuberculous  subjects, 
and  could  not  find  it  in  as  large  a  proportion  of  cases  as  Freund  and 
Hart  reported. 

Arthur  Keith,-  Stiller,'^  and  other  authors  are  inclined  to  look  upon 
this  deformity  of  the  thoracic  girdle  rather  as  a  result  of  tuberculosis 
than  a  cause  of  it.  Pottenger'*  points  out  that  the  muscle  changes  de- 
scribed by  Freund  as  hypertrophic  and  due  to  overwork,  caused  by 
the  muscle  pulling  against  an  ankylosed  rib,  is  more  likely  a  contrac- 
tion of  the  muscle  caused  by  the  inflammation  within  the  lung  reflexly 
through  the  spinal  cord.    It  is  also  probable,  according  to  Pottenger, 

1  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1913,  xxvi,  630. 

2  Further  Advances  in  Physiology,  1909. 

3  Berl.  klin.  Wchnschr.,  1912,  xlix,  97. 

■*  Muscle  Spasm  and  Degeneration,  St.  Louis,  1911. 


88      FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

that  the  cause  of  the  ossification  of  the  cartilage  and  ankylosis  of  the 
costosternal  and  sternomanubrial  articulations  is  also  a  reflex.  "The 
contraction  of  the  muscles  covering  the  apex,  together  with  the  limited 
motion  on  the  part  of  the  diaphragm  which  is  present  in  even  small 
pulmonary  lesions,  together  with  the  decreased  expansibility  and 
lessened  elasticity  of  the  parenchyma  of  the  underlying  lung,  caused 
by  the  inflammatory  process  within,  are  causes  of  lessened  motion 
at  the  apex;  and  that  these  conditions,  together  with  the  trophic 
changes  which  occur  in  the  bone  and  cartilage  as  a  result  of  the  reflex 
stimulation  of  the  nerves  which  supply  these  structures,  favor  anky- 
losis and  ossification." 

Of  course,  the  suggestions  made  by  several  authors  that  operative 
interference  is  indicated  in  cases  with  stenosis  of  the  upper  aperture 
of  the  thorax  for  the  prevention  or  cure  of  phthisis,  is  rather  premature. 
But  it  appears  that  among  the  many  predisposing  causes  of  this  disease, 
the  thoracic  anomaly  just  described  may  play  an  important  role.  At 
any  rate,  it  is  worth  while  to  continue  investigations  along  these  lines. 

Diseases  of  the  Respiratory  Tract  as  Predisposing  Factors. — Of 
the  diseases  which  have  at  one  time  or  another  been  considered  pre- 
disposing to  phthisis,  those  affecting  the  respiratory  tract  are  nearly 
always  mentioned  as  preparing  a  favorable  soil  for  the  growth  of 
tubercle  bacilli.  Thus,  we  occasionally  meet  w^ith  cases  of  bronchi- 
ectasis, syphilis,  actinomycosis  and  cancer  of  the  lungs  and  chronic 
pneumonia,  in  which  tuberculosis  is  implanted  at  the  site  of  the 
primary  disease.  There  are  two  plausible  explanations  for  these 
phenomena:  In  most  cases  it  is,  in  all  probabilities,  an  old,  dormant 
tuberculous  lesion,  dating  back  to  childhood,  that  is  reawakened  into 
activit}'^  by  the  new  disease,  assisted  by  the  reduction  in  vitality  and 
resisting  power  of  the  patient.  In  pneumokoniosis  the  non-tubercu- 
lous lesion  in  the  lung  produces  a  local  ischemia,  obstructs  the  lymph 
channels,  and  thus  prevents  absorption  or  destruction  of  any  tubercle 
bacilli  that  may  be  brought  in  by  the  air  stream.  Pure  lobar  pneumonia 
is  hardly  ever  followed  by  phthisis  and,  in  most  cases  in  which  it  was 
said  to  have  been  observed,  the  probabilities  are  in  favor  that  the 
primary  disease  was  acute  pneumonic  phthisis  which  had  subsided 
and  followed  the  course  of  chronic  phthisis.  Especially  is  this  the 
case  with  apical  pneumonia,  and  basal  phthisis,  and  many  of  the  so- 
cafled  "unresolved  pneumonias"  have  been  tuberculous  from  the 
start. 

Pleurisy. — Of  greater  importance  is  the  etiological  relation  of  pleurisy 
to  phthisis.  Of  course,  the  secondary  pleurisies,  those  occurring  in 
cases  of  thoracic  neoplasms,  cardiac  and  renal  disease  have  no  signifi- 
cance in  this  regard.  But  the  forms  of  acute  and  chronic  pleurisy 
which  have  been  formerly  considered  "idiopathic,"  appear  to  be, 
in  the  vast  majority  of  cases,  of  a  tuberculous  nature,  though  many 
are  undoubtedly  rheumatic. 

This  important  fact  was  first  ascertained  in  this  country  l)y  Vincent 


DISEASES  OF  THE   UPPER  RESPIRATORY  PASSAGES        89 

Y,  Bowditch/  of  Boston,  who  found  that  out  of  90  cases  of  acute  pleurisy 
which  had  been  observed  by  his  father  and  followed  up  by  himself 
between  1849  and  1879,  32  died  of,  or  had,  phthisis.  Many  others, 
notably  Landouzy,  Vaillard,  Kelsch,  Osier,  and  Koniger'  have  also 
shown  that  between  50  and  80  per  cent,  of  patients  with  pleurisy 
develop  phthisis  subsequently. 

In  the  histories  of  tuberculous  patients  we  often  elicit  that  pleurisy 
preceded  the  onset  of  phthisis.  Allard  and  Koster^  analyzed  2123 
cases  of  phthisis  and  found  in  650  a  history  of  idiopathic  pleurisy. 
These  authors  conclude  that  47.7  per  cent,  of  cases  of  idiopathic  pleurisy 
sooner  or  later  develop  phthisis;  in  the  cases  of  dry  pleurisy  the  per- 
centage was  42.  On  the  other  hand,  von  Ruck  and  Bosanquet  found 
only  5  per  cent,  of  consumptives  with  a  history  of  pleurisy.  Clifford 
Allbutt,^  in  a  review  of  the  subject,  arrives  at  the  same  conclusion. 

It  appears  that  in  the  young,  under  fifteen  years  of  age,  the  propor- 
tion of  pleurisies  that  are  of  a  tuberculous  character  is  less  than  in 
adults.  In  fact,  only  exceptionally  does  tuberculosis  develop  in  a  child 
after  it  has  passed  through  an  attack  of  dry  or  wet  pleurisy.  Perhaps 
the  same  factors  are  operative  which  prevent  the  development  of 
phthisis  in  all  young  persons  before  fourteen  years  of  age,  though 
tubercle  bacilli  are  rare  in  the  exudates  in  the  young. 

Strictly  speaking,  pleurisy  cannot  be  considered  as  a  predisposing 
cause  of  phthisis,  because  it  appears  that  it  is  essentially  tuberculous. 
Tubercle  bacilli  have  been  found  in  the  exudates  of  between  50  and 
80  per  cent,  of  cases,  and,  since  the  antiformin  method  has  been  used, 
the  proportion  is  even  higher.  It  is  practically  established  that  most 
cases  of  "idiopathic"  pleurisy  are  caused  by  tubercle  bacilli.  This 
means  that  it  is  not  predisposing  to  phthisis,  but  that  patients  with 
pleurisy  are  actually  tuberculous  from  the  start. 

On  the  other  hand,  it  appears  from  available  clinical  evidence  that 
pleurisy  has  a  remarkably  favorable  influence  on  the  tuberculous  pro- 
cess in  the  lungs.  In  far-advanced  cases  of  phthisis  the  disease  may  be 
arrested  with  the  onset  of  pleurisy,  especially  if  an  effusion  occurs; 
in  many  cases  we  have  observed  a  cure.  Some  believe  that  in  such 
cases  it  was  the  mechanical  influence  of  the  effusion,  or  the  pain  restrict- 
ing the  respiratory  excursions  of  the  affected  side,  that  afforded  rest  to 
the  lung  and  thus  favored  the  healing  process,  as  is  the  case  with  an 
artificial  pneumothorax.  But  this  does  not  explain  all  cases,  and  some 
are  inclined  to  attribute  the  favorable  influence  of  pleurisy  on  phthisis 
to  complex  biochemical  processes. 

Diseases  of  the  Upper  Respiratory  Passages.— We  often  meet  with 
persons  who  have  sufi^ered  for  years  from  frequent  "colds,"  showing 
inflammatory  changes  in  the  nose,  rhinopharynx  and  pharynx,  recur- 
rent bronchitis  and  tracheitis,  and  finally  tuberculosis  develops.    Espe- 

1  Trans.  Amer.  Climatol.  Assn.,  1889,  vi,  1. 

=  Zeitschr.  f.  Tuberkulose,  1911,  xvii,  521;    xviii,  417. 

3  Hygiea,  1911,  Ixxiii,  1105.  "  Lancet,  1912,  ii,  1485, 


90     FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

cially  in  children  with  chronic  nasal  catarrh  or  adenoids,  tuberculosis 
has  been  stated  to  be  very  frequent.  The  fact  that  these  young  sub- 
jects often  have  enlarged  cervical  glands  has  contributed  to  the  as- 
sumption of  their  predisposition.  As  a  manifestation  of  the  traditional 
"scrofula"  also  these  morbid  phenomena  have  been  considered  as  in 
themselves  tuberculous. 

Microscopic  studies  of  tonsils  and  adenoids,  and  inoculation  experi- 
ments by  Walsham,  Dieulafoy,  and  others  have  shown  that  tubercle 
bacilli  are  often  found  in  these  organs.  But  it  appears  from  all  avail- 
able evidence,  clinical  experience,  animal  experimentation  and  histo- 
logical studies  of  tonsils  and  adenoids,  that  they  by  no  means  contain 
tubercle  bacilli  in  such  large  numbers  as  to  be  a  cause  of  tuberculosis, 
and  as  a  point  of  entry  of  the  bacilli  into  the  body,  the  pharyngeal 
tonsil  plays  only  a  subordinate  role,  if  any. 

Pulmonary  Emphysema  and  Asthma. — Of  interest  is  the  relation  of 
pulmonary  emphysema  and  asthma  to  phthisis.  Rokitansky  said  that 
pulmonary  emphysema  and  tuberculosis  occupy  a  relation  of  mutual 
exclusion;  and  Trousseau  considered  asthma  and  tuberculosis  as  an 
expression  of  the  same  diathesis.  Asthmatic  patients  may  bring 
forth  tuberculous  children,  and  conversely,  tuberculous  parents  may 
have  asthmatic  children.  Brugelmann  says  that  the  contrary  is  true 
— as  long  as  one  has  asthma  he  is  immune  to  tuberculosis,  and  S. 
Wesf^  is  of  the  opinion  that  "phthisical  patients  very  rarely  suffer 
from  spasmodic  asthma,  and  if  an  asthmatic  patient  becomes  phthisi- 
cal, an  event  which  is  by  no  means  common,  the  asthma  usually  dis- 
appears." This  is  in  agreement  with  the  view  of  F.  A.  Hoffmann,- 
who  says  that  when  the  two  diseases  combine,  each  gives  up  a  part  of 
its  peculiarities;  the  asthma,  its  characteristic  paroxysmal  character 
— the  attack  becomes  weak  and  indistinct  and  passes  over  into  indefi- 
nite dyspneic  conditions;  the  tuberculosis,  its  progressive  character 
— it  is  prolonged  and  degenerates  into  fibroid  phthisis.  The  same 
author  considers  an  emphysematous  lung  as  a  distinctly  unfavorable 
soil  for  the  development  of  tuberculosis,. 

My  own  experience  leads  me  to  agree  only  partly  with  these  views. 
True  bronchial  asthma  is  only  rarely  complicated  by  phthisis,  in  fact 
I  have  hardly  seen  half  a  dozen  cases  in  which  this  has  happened. 
The  paroxysmal  attacks  of  cough  and  dyspnea  seen  in  some  consump- 
tives have  often  been  mistaken  for  asthma,  but  a  careful  consideration 
of  the  history  and  symptomatology  of  the  case  shows  that  they  are  but 
pseudo-asthmatic  attacks,  encountered  almost  exclusively  in  fibroid 
phthisis,  and  at  times  in  cases  of  acute  pneumonic  phthisis.  It  is 
different  with  pulmonary  emphysema.  I  have  seen  many  cases  of 
emphysema  complicated  by  tuberculosis,  particularly  in  workers  at 
dusty  trades,  garment  workers,  furriers,  rag-pickers,  etc.     It  appears, 

1  Diseases  of  the  Organs  of  Respiration,  London,  1909,  p.  600. 

2  In  Nothnagel's  Practice,  Amer.  ed.,  Disease  of  the  Bronchi,  Lungs  and  Pleura,  1903, 
pp.  241,  291. 


DISEASES  OF   THE  HEART  AND   BLOODVESSELS  91 

however,  that  the  tuberculosis  pursues,  as  a  rule,  an  exceedingly  mild 
course  and  is  very  difficult  of  diagnosis,  excepting  by  a  microscopic 
examination  of  the  sputum. 

In  this  connection  it  is  well  to  bear  in  mind  the  difference  in  the 
ages  at  which  these  two  diseases  are  most  likely  to  occur:  Phthisis  is 
mostly  a  disease  of  adolescents  and  adults  before  thirty,  while  emphy- 
sema is  mainly  seen  in  persons  over  forty  years  of  age.  It  is  in  the  latter 
class  that  tuberculosis  often  develops  in  an  emphysematous  lung. 
Emphysema  is  also  frequently  seen  in  chronic  phthisis  which  has 
healed,  and  also  in  the  unaffected  lung  or  parts  of  the  lung  in  patients 
with  active  phthisis. 

The  reasons  why  asthma  and  emphysema  are  some  protection 
against  phthisis  are  not  clear.  Some  are  inclined  to  attribute  it  to 
the  atrophic  condition  of  the  pulmonary  parenchyma  which  renders 
it  unfavorable  for  the  growth  of  the  bacilli;  others  believe  that  because 
the  inspiratory  current  is  slow  and  inadequate,  it  cannot  bring  bacilli 
deeply  into  the  lung.  Perhaps  the  venous  hyperemia,  which  is  present 
in  most  cases  of  emphysema,  prevents  the  development  of  phthisis 
like  certain  forms  of  heart  disease  do. 

Diseases  of  the  Heart  and  Bloodvessels. — Diseases  of  the  heart 
have  also  been  found  etiologically  related  to  the  development  of 
phthisis.  Louis,'  in  1836,  pointed  out  that  the  heart  of  the  consumptive 
is  small,  and  ever  since  considerable  evidence  has  accumulated  showing 
that  the  size,  capacity  and  thickness  of  the  walls  of  this  organ  are 
usually  smaller  in  the  consumptive  than  in  healthy  persons.  Many 
authors  even  consider  a  congenital  hypoplasia  of  the  cardiac  muscle 
a  prerequisite,  or  at  least  a  predisposing  factor,  in  phthisis.  That  an 
hypertrophied  heart  is  exceedingly  rare  in  phthisis  is  well  known  to 
all  who  have  examined  chests  with  the  aid  of  radioscopy,  or  made 
autopsies  on  persons  who  died  from  tuberculosis. 

Careful  pathological  research  has,  however,  shown  that  in  the  incip- 
ient stage  the  heart  is  of  normal  size  and  that  with  the  progress  of  the 
disease  it  participates  in  the  wasting  process  of  the  organs  of  the  body, 
especially  the  muscles.  In  other  words,  the  small  heart  is  an  expres- 
sion of  the  general  cachexia  of  phthisis,  a  phenomenon  often  observed 
in  other  wasting  diseases,  notably  cancer.  But  even  this  is  denied  by 
some  competent  observers.  Sir  Douglas  Powell-  says:  " I  have  always 
held  the  belief  that  the  heart  in  pulmonary  tuberculosis  did  not  par- 
take in  the  wasting  of  other  muscles,  and  although  perhaps  not  abso- 
lutely of  normal  weight,  was  yet  relatively,  or  perhaps  more  than 
relatively  so,  in  relation  to  the  body  weight.  My  impression  clinically, 
too,  is  that  the  right  side  of  the  heart  is  relatively  somewhat  enlarged 
and  thickened  in  the  chronic  forms  of  the  disease." 

On  the  whole  it  can  be  stated  that  a  small  heart  is  not  a  predisposing 
factor  in  phthisis,  as  has  been  assumed  by  some  authors.     Even  the 

'  Recherches  anatomico-pathologiques  sur  la  phtisie,  Paris,  1825. 
2  Lancet,  1912,  ii,  1415. 


92     FACTORS  PREDISPOSING  TO  EVOLUTION  OF  PHTHISIS 

suggestion  that  a  small  heart  may  cause  relative  anemia  of  the  lungs 
does  not  hold,  as  a  rule,  because,  while  it  is  true  that  with  each  beat  a 
lesser  amount  of  blood  is  propelled  to  the  lungs,  this,  however,  is  com- 
pensated by  the  greater  frequency  of  the  heart  beat. 

But  a  large  and  hypertrophied  heart  appears  to  a  certain  extent  a 
protection  against  the  development  of  phthisis.  This  is  seen  in  the 
case  of  valvular  disease,  especially  of  the  left  side  of  the  heart.  As  far 
back  as  1844  Rokitansky^  asserted  that  diseases  of  the  heart  and  blood- 
vessels producing  passive  congestion  of  the  lungs  are  a  preventive 
of  phthisis.  Traube  later  modified  this  law  by  saying  that  only 
mitral  stenosis  excludes  phthisis,  while  in  aortic  disease  tuberculosis  is 
occasionally  met  with.  Fagge  also  held  that  mitral  stenosis  is  almost  a 
complete  bar  to  tuberculosis,  the  postmortem  records  of  Guy's  Hospital 
supplying  only  4  cases  in  the  course  of  thirty  years.  Percy  Kidd's^ 
statistics  give  only  1  instance  in  500  cases,  and  Walsham's,  1  in  130 
cases. 

Inasmuch  as  this  point  has  lately  been  contested  in  this  country 
by  Xorris,  Burns,  and  others,  it  is  worth  while  to  find  out  what  autopsies 
made  in  recent  times  have  revealed.  Among  4359  autopsies  performed 
by  Birch-Hirschfeld,  he  found  that  907,  or  20.8  per  cent.,  presented 
lesions  of  chronic  pulmonary  tuberculosis;  among  107  with  valvular 
lesions,  only  5,  or  4.6  per  cent.,  showed  tuberculous  lesions  in  the  lungs, 
and  of  these  the  heart  defect  was  in  the  pulmonary  valve  in  2.  In 
other  words,  only  3  cases  of  mitral  disease  with  tuberculosis  were 
found  in  this  large  material.  Norris^  collected  from  the  literature 
records  covering  8154  autopsies  on  tuberculous  subjects  where  only 
3.5  per  cent,  showed  signs  of  valvular  heart  disease.  While  personally 
performing  1764  autopsies  on  tuberculous  subjects  he  found  130, 
or  7.3  per  cent.,  of  valvular  disease.  Anders^  calculated  only  1.2  per 
cent,  in  10,687  autopsies,  and  Browai^  collected  figures  of  71,115 
autopsies  with  but  0.9  per  cent,  of  valvular  heart  disease  in  phthisis. 
Statistics  like  these  show  more  conclusively  than  clinical  observations 
the  rarity  of  phthisis  with  mitral  defects.  Endocarditis  may  occur 
in  the  course  of  phthisis,  as  a  complication,  but  in  the  majority  of 
cases  it  appears  after  the  onset  of  tuberculosis;  it  only  rarely  precedes 
it.  As  a  terminal  affection  it  is  not  rare,  and  then  is  usually  due  to 
staphylococci,  streptococci  and  is,  as  a  rule,  verrucose  in  type.  Tuber- 
culous endocarditis  does  occur,  but  it  is  exceedingly  rare. 

Murmurs  in  phthisical  subjects  do  not  mean  endocarditis,  as  a  rule. 
They  are  usually  due  to  fatty  degeneration  of  the  heart  with  dilatation, 
pleuropericardial  adhesions,  cardiac  displacement,  etc.  The  latter 
may  even  produce  arrhythmia.     C.  M.  Montgomery''  found  murmurs 

1  Handbuch  der  patholog.  Anatomie,  Vienna,  1844,  ii,  520. 

=  St.  Bartholomew's  Hosp.  Rep.,  xxiii,  239. 

3  Amer.  Jour.  Med.  Sci.,  1904,  cxxviii,  649. 

^  Ibid.,  1909,  cxxiii,  93.  *  Ibid.,  c-xxxvii,  186. 

6  Ibid.,  1910,  cxxxix,  870. 


DIABETES  93 

in  three-fourths  of  all  advanced  cases  of  phthisis,  although  in  his  171 
cases  of  pulmonary  tuberculosis  a  positive  diagnosis  of  endocarditis 
was  made  only  in  2.  Similarly,  N.  B.  Burns's^  cases  were  diagnosed 
merely  by  the  murmurs  which  were  audible  over  the  cardiac  region, 
and  he  says  that  most  of  them  were  complications  of  phthisis. 

In  my  own  experience,  I  have  seen  but  5  or  6  cases  of  true  mitral 
stenosis  developing  phthisis.  To  be  sure,  I  have  met  with  presystolic 
murmurs  at  the  apex,  but  these  murmurs,  as  well  as  the  decompensa- 
tion, appeared  long  after  the  onset  of  phthisis,  mostly  as  a  terminal 
phenomenon. 

It  seems  that  mitral  stenosis  causes  a  mechanical  impediment  to 
the  lesser  circulation,  thus  creating  congestion  or  plethora  of  the  blood- 
vessels in  the  lungs,  and  this  has  been  offered  as  an  explanation  for  the 
antagonism  between  this  disease  and  phthisis.  But  it  must  be  borne 
in  mind  that  in  compensated  mitral  stenosis  the  lungs  do  not  have 
a  larger  quantity  of  blood  than  normally;  it  is  only  with  the  onset  of 
decompensation  that  the  pressure  is  elevated  and  the  blood  stream 
is  slowed,  thus  favoring  a  larger  quantity  of  blood  in  the  lungs. 

Those  who  accept  the  hematogenous  origin  of  phthisis  explain  that 
in  this  manner  the  smaller  vessels  are  dilated  and  the  opportunity 
for  development  of  emboli  of  tubercle  bacilli  is  reduced  to  a  minimum. 
In  mitral  stenosis  the  congestion  of  the  pulmonary  vessels  is  greater 
than  in  insufficiency,  and  for  this  reason  phthisis  is  more  rarely  encoun- 
tered in  the  former  than  in  the  latter. 

In  congenital  heart  disease,  pulmonary  stenosis  appears  to  predis- 
pose to  phthisis  and  those  who  survive  infancy  and  childhood  with 
such  heart  lesions,  succumb  during  adolescence  to  tuberculosis  because 
of  the  defective  circulation  of  blood  and  lymph  in  the  lungs  which  this 
cardiac  defect  brings  about. 

Diabetes. — For  a  long  time  diabetes  has  been  considered  as  favor- 
ing the  evolution  of  phthisis.  It  has  been  stated  that  the  two  diseases 
are  very  frequently  associated  and  that  phthisis  in  diabetics  pursues 
a  peculiar  course,  ending  fatally  in  a  short  time.  That  glycosuria 
predisposes  to  tuberculosis  has  also  been  inferred  from  the  fact  that  in 
animals  the  same  condition  has  been  observed.  Thus,  Schindelka 
reported  pulmonary  tuberculosis  in  a  diabetic  dog,  and  canines  are 
usually  very  refractory  to  tuberculosis. 

The  first  to  collect  statistics  on  the  subject  was  Griesinger  who, 
in  1859,  reported  250  cases  of  diabetes  in  whom  he  found  42  per  cent, 
affected  with  tuberculosis.  Windle  even  found  that  50  per  cent,  of 
327  diabetics  died  from  tuberculosis.  But  a  more  recent  and  thorough 
survey  of  the  evidence  by  Charles  M.  Montgomery^  shows  that  there 
is  no  conclusive  proof  that  tuberculosis  occurs  more  frequently  in 
diabetics  than  in  the  general  population  at  the  same  age  periods. 
He  found  that  out  of  355  autopsies  collected  from  the  literature  since 

1  Anier.  Jour.  Med.  Sci.,  1914,  cxlvii,  866.  '  Ibid.,  1912,  cxliv,  o43. 


94      FACTORS  PREDISPOSING  TO  EVOLUTION  OF  PHTHISIS 

1882,  including  his  own  25  cases,  138,  or  38.9  per  cent.,  revealed  pul- 
monary tuberculosis,  mostly  in  an  acute  form.  This  cannot  be  said  to 
be  very  excessive  if  we  consider  the  frequency  of  tuberculosis  in  the 
general  population  at  the  ages  between  twenty  and  fifty. 

It  appears  that  diabetes  hardly  ever  occurs  in  phthisical  subjects. 
Whenever  the  two  diseases  are  found  in  the  same  subject,  the  former 
was  invariably  the  first  disease.  West,  Raw,  Montgomery,  and  others 
agree  with  this  view.  In  my  own  experience,  dealing  with  several 
thousand  consumptives  derived  from  a  class  (Jews)  peculiarly  predis- 
posed to  diabetes,  I  have  never  seen  one  developing  glycosuria  while 
suflFering  from  active  phthisis.  The  reasons  for  this  peculiarity  are 
obscure. 

While  in  most  cases  tuberculosis  occurring  in  diabetics  runs  a 
rapidly  fatal  course,  which  could  be  expected  a  priori  considering  that 
both  are  wasting  diseases,  I  have  seen  many  who  lived  on  for  many  years. 
As  Montgomery  says,  "Often  each  disease  runs  a  course  apparently 
independent  of  the  other."  We  often  see  patients  improving  as  regards 
their  glycosuria  or  the  pulmonary  condition,  or  even  both.  I  have 
a  patient  who  has  been  diabetic  and  tuberculous  for  twelve  years 
doing  very  well,  excepting  for  occasional  acute  exacerbations  of  either 
condition. 

Acute  Infectious  Diseases. — ^It  has  repeatedly  been  stated  that  the 
endemic  contagious  diseases,  like  measles,  scarlet  fever,  whooping- 
cough,  diphtheria,  etc.,  are  often  followed  by  phthisis,  and  in  infants 
and  children  tuberculous  bronchopneumonia  is  frequently  a  sequel 
of  measles  and  whooping-cough.  This  heightened  predisposition  may 
be  explained  as  depending  on  the  general  disturbance  in  health  caused 
by  the  fever,  catarrh  of  the  respiratory  passages,  etc.,  which  reduce 
the  resisting  power  and  produce  a  soil  favorable  for  the  activation  of 
dormant  foci  of  tubercle  bacilli,  or  favor  new  infections.  The  diseases 
are  accompanied  to  a  great  extent  by  irritation  of  the  mucous  mem- 
branes and  defects  in  the  epithelium  which  facilitate  the  entrance  of 
the  bacilli,  so  that  infection  of  the  respiratory  passages  is  particularly 
favored.  The  influence  of  measles  and  whooping-cough  may  be  purely 
mechanical;  fits  of  violent  cough  are  liable  to  rupture  tuberculous 
glands  in  the  chest. 

But  E.  P.  Copeland^  points  out  that  "taking  into  consideration  the 
enormous  morbidity  of  measles,  whooping-cough  and  influenza,  the 
incidence  of  tuberculosis  as  a  complication  or  sequel  is  of  relatively 
small  importance;  that  its  development  is  all  but  invariably  dependent 
upon  the  preexistence  of  the  latent  disease;  and  that  its  dissemination 
is  probably  due  to  lymphatic  activity  resulting  from  the  pulmonary 
inflammation  associated  with  these  diseases." 

That  these  diseases  may  be  strong  predisposing  factors  to  tubercu- 
lous infection  and  the  extension  of  existing  tuberculous  disease,  was 

»  Sixth  Intern.  Congr.  Tuber.,  1908,  ii,  379. 


TYPHOID  FEVER  95 

shown  from  another  viewpoint.  "Allergy,"  or  the  altered  reactivity 
of  the  organism  to  tuberculin,  which  is  apparently  dependent  upon 
the  fact  that  the  body  has  produced  antibodies  which  counteract  the 
effects  of  tuberculous  toxemia,  is  diminished  in  intensity  or  disappears 
altogether  during  an  attack  of  measles.  This  "  anergy"  would  indicate 
that  resistance  to  infection  has  diminished,  just  as  in  far-advanced 
phthisis  for  a  short  period  before  the  fatal  termination,  in  miliary 
tuberculosis,  etc.,  when  all  defensive  powers  have  failed.  Von  Pirquet 
has  named  this  state  "anergic,"  i.  e.,  non-reacting.  He  assumes  that 
the  measles  process  occupies  the  antibodies  which  are  needed  for  the 
repulsion  of  the  tubercle  bacilli  present  in  the  body.  During  this 
unprotected  period  the  tubercle  bacilli  can  grow  and  pass  through  the 
necrotic  walls  of  a  caseous  gland,  or  secondary  diseases  can  also  occur, 
because  now  the  circulating  tubercle  bacilli  can  find  favorable  condi- 
tions where  at  other  times  they  would  have  been  destroyed.  He  draws 
an  analogy  between  this  condition  and  the  condition  favoring  the  prog- 
ress of  tuberculosis  in  the  adult — general  debility  due  to  malnutrition, 
overwork  or  any  other  condition  robbing  the  body  of  its  natural  defences. 

Influenza. — The  connection  between  influenza  and  phthisis  is  even 
less  clear.  During  the  great  pandemic  of  influenza  in  1891  it  was 
observed  that  the  mortality  was  increased,  and  similar  observations 
had  been  made  before.  It  was  therefore  concluded  that  influenza 
is  a  strong  predisposing  factor  in  tuberculosis.  But  carefully  studying 
the  true  conditions,  we  find  that  it  was  only  the  mortality  from  phthisis 
that  was  increased,  and  not  the  morbidity.  Moreover,  even  this  has 
not  been  lasting,  for  the  mortality  has  been  steadily  declining  despite 
the  fact  that  influenza  has  been  endemic  all  over  the  civilized  world 
during  the  past  thirty  years.  Clinically,  we  find  that  when  a  consump- 
tive is  subjected  to  an  attack  of  influenza,  the  process  in  the  lung  is 
liable  to  extend,  and  acute  exacerbation  of  the  process  is  likely  to  occur 
which  either  kills  the  patient  or  turns  a  chronic  and  comparatively 
innocuous  process  into  a  subacute  one,  and  finally  to  a  fatal  termination. 
We  see  this  in  hospital  wards  during  epidemics  of  influenza;  the 
mortality  rises 

Typhoid  Fever. — Typhoid  fever  also  has  been  considered  as  predis- 
posing to  phthisis  because  of  the  rather  high  proportion  of  consumptives 
who  give  a  history  of  having  passed  through  an  attack  of  it.  Recently, 
Charles  E.  Woodruffs  has  discussed  the  subject  in  great  detail  and 
arrived  at  the  conclusion  that  typhoid  fever  heads  the  list  of  predis- 
posing causes  of  tuberculosis.  The  fact  that  during  recent  years  the 
mortality  from  tuberculosis  and  from  typhoid  has  been  declining  at 
almost  the  same  rate  is  considered  a  strong  argument.  "The  three 
diseases  which  seem  to  be  most  frequently  followed  by  tuberculosis 
of  the  lungs — measles,  whooping-cough,  and  typhoid — are  all  compli- 
cated with  bronchitis." 

'American  Medicine,  N.  S.,  1914,  xi,  17. 


96      FACTORS  PREDISPOSING  TO  EVOLUTION  OF  PHTHISIS 

There  appears  to  be  a  lack  of  evidence  in  support  of  these  conten- 
tions. The  fact  that  the  mortahty-rates  from  typhoid  and  phthisis 
run  parallel  does  not  prove  that  the  same  cause  is  operative  in  both 
cases.  The  somewhat  excessive  number  of  consumptives  who  have 
a  history  of  typhoid  does  not  convince  in  this  direction.  It  is  well 
known  to  clinicians  that  acute  tuberculosis  very  often  simulates  typhoid 
in  a  striking  manner,  and  with  all  our  diagnostic  methods  it  is  often 
very  difficult  to  differentiate  the  two  diseases.  In  many  cases  of  alleged 
typhoid  preceding  phthisis  I  have  been  convinced  that  it  was  an  acute 
exacerbation  of  latent  tuberculosis  which  was  mistaken  for  tjphoid, 
just  as  many  attacks  of  "grippe"  are  in  reality  acute  exacerbations  of 
chronic  or  mild  forms  of  phthisis.  Typhoid  fever,  like  most  other 
febrile  diseases,  may,  however,  activate  latent  phthisis  which  might 
not  have  taken  an  acute  or  subacute  course  otherwise.  But  under  the 
circumstances  we  cannot  consider  typhoid  'per  se  as  predisposing  to 
tuberculosis. 

OCCUPATION. 

Of  the  factors  which  have  been  mentioned  as  predisposing  to  the 
development  and  evolution  of  phthisis,  the  character  of  the  occu- 
pation of  the  patient  has  been  given  prominence  by  nearly  every 
writer  on  the  subject.  Very  few,  however,  have  looked  at  this  problem 
with  the  view  of  William  Gilman  Thompson,  who  justly  says  that 
"it  is  often  not  the  occupation  which  is  at  fault,  but  the  manner  in 
which  it  is  conducted." 

Dust  as  an  Etiological  Tactor  in  the  Evolution  of  Phthisis. — Long 
ago  Ramazzini  spoke  of  the  etiology  and  relations  of  dust  to  diseases 
of  the  respiratory  tract  and  at  present,  after  we  have  studied  the 
etiology  of  tuberculosis  on  a  scientific  basis,  we  find  that  the  ancient 
clinician's  observations  have  been  confirmed  in  the  main.  In  nearly 
all  treatises  on  tuberculosis,  or  on  occupational  diseases,  it  is  never 
omitted  to  state  emphatically  that  persons  pursuing  occupations 
at  which  they  are  exposed  to  the  inhalation  of  mineral,  metallic, 
vegetable,  or  animal  dust  are  more  likely  to  contract  tuberculosis 
and  die  from  it  than  others.  According  to  data  obtained  by  the 
Twelfth  Census  of  the  United  States  the  death-rate  from  phthisis 
was  5.41  per  thousand  among  marble-  and  stone-cutters,  as  against 
only  1.12  per  thousand  among  farmers  and  planters,  and  1.07  among 
lumbermen  and  raftsmen.  Statistics  published  by  the  United  States 
Bureau  of  Labor  in  1908-1909  show  that  the  mortality  from  tuber- 
culosis among  males  from  twenty-five  to  thirty-four  years  of  age 
constituted  31  per  cent,  of  the  total  mortality  in  the  working  popula- 
tion. But  among  grinders  it  was  71  per  cent.;  among  tool-makers, 
59  per  cent. ;  printers,  50  per  cent. ;  stone-cutters  and  weavers,  55  per 
cent.;  spinners,  50  per  cent.;  woolen-workers,  44  per  cent.  Similar 
statistics  are  available  for  many  other  countries,  and  for  other  occupa- 
tions in  which  the  workers  are  exposed  to  the  inhalation  of  mineral 


OCCUPATION  97 

and  metallic  dust,  especially  grinders,  tool-  and  instrument-makers, 
printers,  etc.  From  a  report  of  the  Bureau  of  Labor  in  New  York, 
it  appears  that  the  trades  that  showed  the  least  effects  from  the  ravages 
of  consumption  were  the  boot-  and  shoemakers,  and  millers. 

It  would  seem  that,  with  the  exceptions  to  be  mentioned  later, 
mineral  dust  is  the  most  dangerous  in  this  regard,  as  has  been  shown 
by  W.  Zeuner,!  Harlow  Brooks,^  Frederick  Hoffman,^'  and  others. 
Undoubtedly,  it  is  the  jagged  and  sharp-pointed  particles  which  act 
as  an  irritant  to  the  pulmonary  tissues.  Nature  has  placed  many 
barriers  m  the  way  of  even  fine  dust  entering  into  the  deep  respira- 
tory passages  with  the  inspired  air;  even  when  reaching  the  mucous 
membrane  of  the  bronchi  and  lung,  the  latter  are  very  tolerant  and  most 
of  it  is  soon  expelled  with  the  expectoration.  But  Moritz  found  that 
the  sensibility  of  the  respiratory  tract  from  the  nose  to  the  trachea  is 
reduced  in  persons  working  as  grinders  in  a  steel  factory  in  Germany. 
Large  masses  of  metallic  dust  could  be  seen  lying  on  the  vocal  cords 
and  mucous  membrane  of  the  trachea  without  provoking  cough. 
For  this  reason  some  dust  often  remains  and  is  taken  up  by  the  lymph 
channels  and  carried  away.  But  after  persistent  deposits  of  dust  in 
the  alveoli,  the  irritation  it  produces  excites  a  reactive  inflammation, 
clogs  up  the  lymph  channels  and  lowers  the  resisting  powers  of  the 
invaded  lung,  preparing  the  soil  for  the  deposit  of  tubercle  bacilli 
which  may  thrive  in  such  defective  areas  of  lung  tissue.  The  glands 
of  the  lungs  act  as  filters  which  retain  the  dust  brought  in  by  inhalation. 
But  if  new  deposits  of  dust  are  brought  repeatedly  into  these  glands 
they  are  ultimately  doomed  to  become  damaged  and  their  function 
as  filters  impaired,  or  even  abolished.  They  are  supersaturated  with 
dust  and,  like  a  sponge  which  is  supersaturated,  can  absorb  no  more. 
Zeuner  is  of  the  opinion  that  the  glands  of  the  deeper  respiratory 
passages  produce  an  internal  secretion  which  is  bactericidal,  destroying 
any  microorganism  that  may  enter  with  the  inspired  air,  including 
tubercle  bacilli;  at  all  events,  it  prevents  their  growth.  Dust  destroys 
the  structure  and  function  of  these  glands. 

It  appears  that  phthisis  in  patients  with  pneumokoniosis  is  often  of 
a  special  form,  pursuing  a  slow,  sluggish  course  and  with  a  symptoma- 
tology peculiarly  its  own.  Fibroid  phthisis,  which  will  be  discussed 
later  on,  is  mostly  found  in  workers  exposed  to  the  inhalation  of  animal 
or  vegetable  dust.  The  foreign  particles  deposited  in  the  alveoli 
excite  a  productive  inflammation.  At  first,  small  diseased  foci  are 
produced,  but  later,  if  the  irritation  keeps  up,  the  small  foci  coalesce, 
affecting  extensive  areas  of  pulmonary  tissue,  and  tubercle  bacilli, 
either  brought  by  the  inspired  air,  or  by  metastatic  deposits  from  old, 
latent  lesions,  invade  these  areas  secondarily. 

1  Luftereinheit  zur  Bekampfung  der  Tuberkulose,  Berlin,  1903. 

2  Dietetic  and  Hygienic  Gazette,  1907,  xxiii,  709. 

3  Bull.  Bureau  of  Labor,  November,  1908,  p.  633, 


98      FACTORS  PREDISPOSING  TO  EVOLUTION  OF  PHTHISIS 

This  form  of  phthisis  may  last  for  years  without  greatly  incapaci- 
tating the  patient,  who  may  have  no  fever,  no  debility,  no  nightsweats, 
etc. ;  only  cough  and  expectoration,  and  very  often  dyspnea,  being  the 
annoying  features  clinically.  I  have  observed  this  form  of  phthisis 
among  garment-workers,  notably  furriers,  in  New  York  City. 

"In  New  York  City,"  says  William  Oilman  Thompson,^  "a  hotbed 
of  tuberculosis  is  found  in  the  so-called  'sweat-shops'  where  so  much 
ready-made  clothing  is  manufactured.  If  a  man  comes  to  my  Cornell 
Out-patient  Clinic  and  gives  his  occupation  as  'tailor's  presser,'  I 
always  ask  him  at  once  how  long  he  has  had  a  cough.  He  is  almost 
certain  to  have  worked  in  a  densely  crowded,  unventilated  room, 
dusty  from  the  lint  of  clothing,  and  with  his  tailor's  iron  heated  over 
a  gas  stove,  which  adds  to  the  vitiation  of  the  atmosphere.  He  has 
had  long  hours  of  work  and  poor  food.  Thus,  anemic,  ill-nourished  and 
fatigued,  his  body  is  in  ideal  condition  for  the  development  of  the 
germs  of  tuberculosis." 

But  not  all  dust  is  etiologically  related  to  phthisis.  Thus,  among 
coal-miners,  who  undoubtedly  inhale  large  quantities  of  mineral  dust, 
as  is  evident  from  the  frequency  of  pneumokoniosis  among  them, 
true  tuberculous  phthisis  is  comparatively  infrequent.  Kuban  drew 
attention  to  this  fact  as  far  back  as  1863  in  France  where  "coal  dust  is 
unable  to  cause  pulmonary  tuberculosis  or  even  favor  the  evolution 
of  pulmonary  tubercle.  It  prevents  the  development  of  phthisis." 
In  his  book  on  occupational  diseases,  Oliver  shows  that  this  is  true  of 
English  coal-miners,  and  in  the  United  States  Wainwright  and  Nichols^ 
found  that  in  Scranton,  Pa;,  tuberculosis  is  about  two-thirds  less 
frequent  among  miners  than  among  all  other  occupied  males.  Some 
writers  have  attempted  to  explain  this  paradox  by  assuming  that  coal 
dust  possesses  antiseptic  properties,  and  is  rather  a  protection  against 
tuberculosis.  Cornet  suggests  that  in  coal  mines  the  air  is  humid 
and  thus  prevents  desiccation  and  pulverization  of  sputum  which  is, 
of  course,  far-fetched. 

More  noteworthy  is  it  that  street-sweepers  and  coachmen,  in  spite 
of  exposure  to  excessive  inhalation  of  dust,  are  not  excessively  liable 
to  phthisis.  Cornet  concludes  from  this  fact  that  the  dangers  of 
infection  in  the  street  are  nil.  Sommerfeld  has  shown  that  in  Berlin 
the  street-sweepers  have  only  half  the  rate  of  mortality  from  phthisis 
when  compared  with  the  mortality  of  the  working  classes  in  that  city. 
In  New  York  City,  where  several  years  ago  considerable  agitation  was 
made  in  favor  of  protecting  the  street-sweepers  against  the  excessive 
morbidity  and  mortality  from  tuberculosis,  statistics  have  not  borne 
out  these  contentions.  Hofi'man's'  statistics,  gatliered  for  a  monograph 
on  the  excessive  mortality  from  consumption  in  ()C{'U])ations  exposed 
to  municipal  and  general  dust,  show  that  evidently  "tlie  recorded 

1  The  Occupational  Diseases,  New  Yoric,  Ifll  1,  )).  nS. 

2  Amor.  Jour.  Med.  Sci.,  1905,  cxxx,  40."). 

•■'Bull,  Bureau  of  Labor,  November,  lOOS,  p.  033. 


OCCUPATION  99 

mortality  from  consumption  among  men  in  this  employment  is  not 
decidedly  excessive." 

Another  kind  of  dust  which  is  harmless  in  this  regard  is  limestone 
and  also  plaster  of  Paris.  In  England  it  has  been  found,  according 
to  Edgar  L.  Collis/  that  masons  in  districts  where  limestone  is  worked 
do  not  suffer  from  phthisis  in  excess;  while  masons  in  districts  where 
sandstone  is  worked  are  peculiarly  liable  to  succumb  to  this  disease, 
and  have  a  shorter  prospect  of  life.  Halter  and  Garb  have  observed 
the  same  to  be  the  case  in  Germany,  and  G.  Fisac^  reports  that  in 
Spain  the  workers  in  quicklime  and  plaster  of  Paris  are  immune  to 
tuberculosis  despite  the  fact  that  they  live  in  squalid  dwellings  and 
are  underfed.  He  believes  that  their  immunity  is  due  to  the  inhala- 
tion of  dust  containing  lime. 

That  the  chemical  composition  of  the  dust  is  of  more  importance 
than  the  dust  itself  is  well  shown  by  Collis  in  his  Milroy  Ledures  for 
1915.  He  finds  that  when  phthisis  occurs  as  a  result  of  inhalation  of 
mineral  dust,  it  is  always  associated  with  exposure  to  dust  containing 
crystalline  sihca,  though  he  could  find  no  definite  relation  between 
the  amount  of  dust  present  and  the  prevalence  of  phthisis.  As  to 
why  coal  dust,  lime,  plaster  of  Paris,  etc.,  should  be  harmless  in  this 
regard,  while  flint,  slate,  iron,  tin,  lead,  etc.,  do  produce  pulmonary 
tuberculosis,  we  are  at  a  loss,  and  it  may  be  worthy  of  further  study. 

Another  point  brought  out  by  Collis  is  that  phthisis  encountered 
among  workers  at  dusty  occupations  is  actually  due  to  the  inhala- 
tion of  the  dust,  and  not  to  their  mode  of  life.  Outdoor  workers  inhaling 
dangerous  dust  succumb,  while  careless  indoor  workers  at  dusty  occu- 
pations inhaling  dust  containing  no  silica,  or  metallic  fragments,  are 
not  excessively  liable  to  phthisis.  He  finds  that  "dust  phthisis  is 
peculiar  in  showing  a  low  degree  of  infectivity  among  contacts  not 
exposed  to  dust  inhalation."  In  the  lead-mining  districts  of  England, 
there  is  a  larger  proportion  of  widows  than  in  any  other  place  in  the 
kingdom.  Haldane  observed  among  tin-miners  that  "the  wives  and 
children  of  these  men  never  seem  to  be  affected,  although  occupying 
the  same  room  as  the  affected  men  who  never  go  to  the  hospital,  but 
sit  at  home  and  expectorate  sputum  loaded  with  tubercle  bacilli." 
Barwise  noted  the  same  phenomenon  among  gritstone-workers  in 
Derbyshire,  and  it  is  also  true  of  stone-masons  according  to  Collis. 

This  shows  clearly  that  certain  forms  of  dust  are  capable  of  waking 
up  dormant  tuberculous  lesions  in  the  workers;  but  their  wives,  who 
have  assuredly  been  infected  with  tubercle  during  childhood,  cannot 
be  reinfected  with  the  bacilli  expectorated  by  their  husbands.  It 
entirely  agrees  with  our  modern  views  of  tuberculous  infection,  and 
the  difficulty  or  impossibility  of  reinfection  which  is  spoken  of  in 
Chapter  V. 

It  thus  appears  that  occupation  fer  se  cannot  be  considered  as  pre- 

1  Public  Health,  1915;  xxviii,  252,  292;    xxix,  11. 

2  Rev.  de  hig.  y  de  tub.,  1909,  v.  No.  54. 


100    FACTORS  PREDISPOSING  TO  EVOLUTION  OF  PHTHISIS 

disposing  to  phthisis,  with  the  exception  of  those  which  involve  exposure 
to  metalHc  and  certain  kinds  of  mineral  dust.  But  even  in  these 
there  are  exceptions,  as  w^e  saw,  with  street  dust,  coal  dust,  lime- 
stone, plaster  of  Paris,  etc.  Thus,  there  has  been  found  a  relation 
between  the  wages  paid  to  workmen  and  the  incidence  of  phthisis 
among  them.  B.  S.  Warren's^  study  of  conditions  in  the  United 
States  Government  printing  and  engraving  plants  shows  that  despite 
the  fact  that  they  are  badly  overcrowded,  with  poor  ventilation,  etc., 
the  mortality  from  tuberculosis  is  rather  low  among  the  employees. 
The  reason  he  assigns  is  that  they  receive  good  wages.  He  finds  from 
census  statistics  that  low  wages  go  hand-in-hand  with  a  high  tubercu- 
losis mortality.  The  difference  in  wages  or  income  means  a  difference 
in  nutrition,  social  contentment,  and  general  welfare  which  renders  the 
farm  laborer  more  susceptible  to  phthisis  than  his  employer,  and  the 
cotton-mill  operative  more  than  the  general  population.  Similarly, 
he  finds  that  of  deaths  among  males  reported  by  the  Census  Bureau 
for  1909,  giving  the  occupation  of  the  deceased,  14.7  per  cent,  were 
from  tuberculosis,  as  against  20.9  per  cent,  among  females.  The  reasons 
for  this  disparity  are  many,  but  undoubtedly  the  inadequate  wages 
paid  to  women  are  responsible  for  a  considerable  portion  of  the  phthisis 
among  female  workers. 

Injury  as  a  Cause  of  Phthisis. — That  traumatism  may  determine 
the  localization  of  extrathoracic  tuberculosis — of  the  bones,  joints, 
glands  and  meninges — is  a  well-known  and  accepted  clinical  fact 
supported  by  the  results  of  animal  experimentation.  But  that  a  local 
injury  to  the  chest  may  be  the  exciting  cause  of  phthisis  is  not  generally 
appreciated  to  the  extent  it  deserves.  It  seems  that  the  older  medical 
literature  only  rarely  referred  to  this  subject,  and  Grasser  could  only 
find  reports  of  about  50  cases  before  1903.  In  the  Prussian  Army  it  was 
observed  that  among  6924  cases  of  phthisis,  95  began  after  an  injury, 
and  of  these  79  had  sustained  contusions  of  the  chest.  This  would 
indicate  that  it  is  more  frequent  than  was  formerly  appreciated. 

It  is  obvious  that  an  injury  per  se  cannot  cause  tuberculosis  of  a 
bone  or  a  joint.  Tubercle  bacilli  must  be  present.  But  in  the  light  of 
our  present  knowledge  of  phthisiogenesis  it  is  clear  that  many,  if  not 
most,  persons  harbor  some  latent  or  healed  tuberculous  foci  with 
virulent  tubercle  bacilli  which  an  injury  may  reawaken  into  activity. 
Kiilbs  has  shown  that  contusions  of  the  chest  often  cause  lacerations 
and  hemorrhages  of  the  pulmonary  parenchyma,  cA'en  when  no  visible 
hemoptysis  occurs,  and  such  lacerated  areas  may  oft'er  a  favorable 
soil  for  the  implantation  of  tubercle  bacilli,  just  as  a  wound  in  a  joint 
or  a  fractured  rib. 

In  his  monograph  on  this  subject  Richard  Stern^  gives  the  following 
direct  and  indirect  possibilities  of  phthisis  after  injury:  (1)  A  per- 
ipheral tuberculosis  of  a  bone  or  joint  may  be  produced  and  this  may 

1  Trans.  Nat.  Assn.  Study  and  Prev.  Tuber.,  1913,  ix,  15;?. 

2  Die  traumatische  Entstehung  innerer  Kraukheiten,  Jena,  1910. 


INJURY  AS  A   CAUSE  OF  PHTHISIS  101 

influence  unfavorably  a  preexisting  tuberculous  lesion  in  the  lung; 
(2)  the  unfavorable  influence  of  loss  of  blood;  (3)  peripheral  throm- 
bosis may  be  caused,  followed  by  pulmonary  infarction  which  may 
ultimately  end  in  secondary  tuberculous  infection;  (4)  the  deleterious 
effects  of  a  long  stay  in  bed,  especially  in  hospitals;  (5)  psychic  depres- 
sion, reducing  the  general  resisting  powers  and  producing  changes  in 
the  constitution  of  the  patient  as  a  result  of  the  accident. 

In  persons  known  to  be  tuberculous  the  disease  may  be  aggravated 
by  an  injury,  as  I  have  seen  in  several  cases,  and  lead  to  a  fatal  termina- 
tion. Especially  is  this  the  case  when  hemoptysis  is  caused  by  the 
injury.  Traumatism  may  also  produce  pleurisy,  usually  dry,  but 
occasionally  with  an  effusion.  Pneumothorax  is  another  possible 
result  of  an  injury  to  the  chest.  In  non-tuberculous  traumatic  pneu- 
mothorax the  rent  in  the  pleura  heals  quickly  and  the  air  is  absorbed, 
but  in  those  with  a  preexisting  tuberculous  lesion  in  the  lung,  active 
or  dormant,  the  usual  course  of  spontaneous  pneumothorax,  hydro- 
thorax,  pyopneumothorax,  etc.,  may  be  followed. 

The  intensity  of  the  injury  should  not  be  taken  as  a  measure  of  the 
probability  of  its  relation  to  phthisis  subsequently  developed,  as  has 
been  pointed  out  by  Wolff-Eisner.  After  violent  injuries  to  bones, 
especially  those  resulting  in  fractures,  tuberculous  osteomyelitis  is 
hardly  ever  observed,  though  slight  injuries  to  bones  may  be  followed 
by  local  tuberculosis.  In  the  same  manner,  as  I  have  seen  in  several 
cases,  a  slight  injury  to  the  chest  may  flare  up  a  latent  tuberculous 
process.  In  persons  known  to  be  healthy  this  is  not  uncommon. 
John  B.  Hawes^  points  out  that  after  the  autumn  football  season  some 
players  develop  consumption  as  a  result  of  injuries  received  on  the 
football  field.  The  special  diet  usually  prescribed  by  the  trainer, 
as  well  as  the  excessive  exertion  for  months  during  the  training  period, 
undoubtedly  reduces  the  resisting  powers  of  even  gridiron  heroes. 

The  site  of  the  lesion  provoked  by  an  injury  is  not  necessarily  at 
the  point  affected  by  the  blow.  Many  authors  have  reported  lesions 
by  contrecouy.  An  acute  general  or  miliary  tuberculosis  may  also 
result  from  breaking  up  of  a  latent  lesion  and  letting  loose  tubercle 
bacilli  into  the  blood  stream.  Hemoptysis  is  not  absolutely  essential 
to  establish  the  relationship  between  the  injury  and  the  phthisis, 
because  laceration  of  the  lung  may  occur  without  causing  hemorrhage. 
When  hemoptysis  occurs,  the  quantity  of  blood  expelled  is  no  criterion 
of  the  size  of  the  torn  vessel.  Nor  must  there  remain  any  external 
marks  on  the  chest  wall  because  an  injury  may  lacerate  the  lung  or 
pleura  without  leaving  any  external  traces. 

The  appearance  of  clinical  symptoms  of  phthisis  may  be  delayed 
for  some  time.  Of  course,  in  cases  of  quiescent  lesions  which  are 
activated  as  a  result  of  traumatism,  the  aggravation  in  the  condition  of 
the  patient,  and  the  extension  of  the  process,  may  appear  soon  after 

1  Boston  Med.  and  Surg.  Jour.,  1913,  clxviii,  83. 


102   FACTORS  PREDISPOSING   TO  EVOLUTION  OF  PHTHISIS 

the  accident,  and  hemoptysis  may  appear  even  immediately.  But  in 
apparently  healthy  persons  the  symptoms  may  appear  many  months 
or  years  later.  Hawes  reports  several  cases  in  which  phthisis  developed 
from  two  to  ten  years  after  the  injury. 

It  takes  about  eight  weeks  for  a  tubercle  to  develop  and  one  tubercle 
is  by  far  not  enough  to  give  symptoms  or  signs  by  which  it  can  be 
recognized  by  the  patient  or  the  physician.  In  fact,  when  a  few  days 
after  an  injury  signs  of  phthisis  are  found,  especially  tubercle  bacilli 
are  found  in  the  sputum,  we  may  conclude  that  we  are  dealing  with  a 
preexisting  disease  which  was,  at  most,  aggravated  by  the  accident. 
But  in  cases  in  which  the  symptoms,  such  as  fever,  emaciation,  cough, 
expectoration,  etc.  make  their  appearance  three  to  six  months  after 
the  injury  in  a  person  known  to  have  been  well  before  the  accident, 
and  the  physical  signs  appear  even  later,  it  is  clear  that  there  was  a 
causative  relation  between  the  injury  and  the  disease.  German  author- 
ities have  limited  the  time  for  the  appearance  of  the  symptoms  after 
the  injury  to  six  months,  although  there  are  undoubtedly  exceptions 
which  must  be  judged  on  their  individual  merits. 


CHAPTER  V. 
PHTHISIOGENESIS. 

Tuberculosis  vs.  Phthisis.  —  After  infecting  an  animal  with 
tubercle  bacilli,  we  know  exactly  what  morbid  phenomena  to  expect. 
On  injecting  into  the  peritoneal  cavity  of  a  guinea-pig  a  certain 
quantity  of  the  pure  culture  of  tubercle  b-ac-iiii,  tuberculous  peritonitis 
soon  develops,  followed  by  tuberculosis  of  other  organs — the  spleen, 
the  liver,  the  kidneys,  etc.,  until  it  finally  succumbs.  But  what 
will  happen  after  a  human  being  is  infected  in  the  usual  spontaneous 
manner  we  cannot  prognosticate  with  any  degree  of  certainty. 
The  individual  may  pass  through  life  without  showing  any  morbid 
manifestations  which  can  be  attributed  to  the  infection.  In  fact, 
the  vast  majority  of  people  have  been  infected  during  their  childhood 
and  are  none  the  worse  for  their  experience,  as  has  already  been  shown. 
A  large  proportion  of  those  in  whom  distinct  lesions  of  a  tuberculous 
character  have  been  found  at  the  autopsy  knew  nothing  about  it  during 
their  life.  On  the  other  hand,  in  a  certain  proportion  the  infection  is 
followed  sooner  or  later  by  some  clinical  form  of  tuberculosis. 

This  is,  however,  not  the  only  difference  between  experimental 
tuberculosis  and  spontaneous  phthisis  as  we  meet  it  in  human  beings. 

It  appears  that  phthisis  is  a  disease  met  with  exclusively  in  human 
beings  and  rarely,  if  ever,  in  the  lower  animals;  certainly  not  in 
animals  which  have  been  infected  experimentally  in  the  laboratory, 
be  it  by  inoculation,  ingestion  or  inhalation  of  tubercle  bacilli.  In 
guinea-pigs,  rabbits,  etc.,  in  whom  spontaneous  tuberculosis  is  ex- 
ceedingly rare,  only  nodular  tubercles  consisting  of  avascular,  cellular 
masses  are  formed  after  experimental  infection;  while  spontaneous 
human  phthisis  is  mainly  a  productive  and  exudative  inflammatory 
process  of  the  lungs  in  which  there  may  or  may  not  be  any  of  the 
characteristic  tuberculous  cell-proliferation.  In  other  words,  in 
animals  it  is  general  or  miliary  tuberculosis  that  we  find,  and  this  is 
also  rarely  met  with  in  humans.  "Real  pulmonary  tuberculosis" 
says  von  Hansemann,^  "in  the  anatomical  sense  is  always  part  and 
parcel  of  general  tuberculosis  of  all  the  organs  in  the  body.  Pure  and 
isolated  pulmonary  tuberculosis  in  the  anatomical  sense,  i.  e.,  in  which 
there  are  no  other  tuberculous  changes  in  the  lungs  than  the  devel- 
opment of  submiliary  tubercles,  never  occurs  as  far  as  my  experience 
goes.  But  it  is  a  noteworthy  fact  that  from  this  disease,  which  in 
reality  alone  deserves  the  name  pulmonary  tuberculosis,  phthisis  never 

'  Berliner  klin.  Wchnschr.,  1911,  xlviii,  1. 


104  PHTHISIOGENESIS 

evolves.  I  know  of  no  case  in  my  own  experience,  nor  from  medical 
literature,  in  which  the  disease  began  as  acute  miliary  tuberculosis  in 
the  anatomical  sense,  and  then  turned  into  pulmonary  phthisis." 
But  phthisis  may  be  complicated  by  general  miliary  tuberculosis.  This 
often  occurs  before  the  fatal  termination  of  the  case. 

In  the  same  sense  we  find  that  Ribbert^  makes  a  sharp  distinction 
between  experimental  tuberculosis  in  animals  and  phthisis  in  human 
beings:  "It  is  undoubtedly  a  fact  that  tubercles  may  be  produced  in 
the  lungs  of  animals  which  are  made  to  inhale  dust  containing  tubercle 
bacilli.  But,  (1)  the  disease  thus  produced  is  not  the  same  as  that 
in  human  beings;  (2)  we  cannot,  without  further  proof,  conclude 
that  human  beings  are  infected  in  the  same  manner.  The  conditions 
under  which  humans  inhale  tubercle  bacilli  are,  at  least  from  the 
viewpoint  of  quantity,  distinctly  different  from  those  prevailing 
during  experimentation.  -It  can  neither  be  proved  that  individuals 
always  inhaled  tubercle  bacilli  before  becoming  sick,  nor  that  the  latter 
settled  primarily  in  the  particular  organ  in  which  they  proliferated. 
Neither  the  clinical  nor  the  anatomical  findings  sufficiently  support 
such  a  view.  It  is  self-understood  that  I  do  not  in  the  least  deny 
that  in  man  also  disease  may  directly  follow  the  inhalation  of  tubercle 
bacilli,  but  it  is  a  question  how  often  this  takes  place.  From  mere 
possibility  to  uncontrovertible  proof  which  will  cover  all  tuberculous 
diseases  of  the  lungs,  is  quite  a  distance."  "Pulmonary  phthisis" 
says  Bacmeister,^  "is  %  disease  found  exclusively  in  adult  human 
beings;  it  never  occurs  spontaneously  in  animals,  nor  has  it  ever 
been  produced  experimentally." 

If  we  want  to  apply  unequivocally  the  experimental  findings  to 
man  we  must  first  demand  that  infection  of  animals  should  result  in 
isolated  apical  lesions  which  should  extend  gradually  downward 
in  the  lung  in  the  typical  chronic  manner.  All  other  forms  of  tuber- 
culosis which  are  produced  experimentally  in  the  lungs  of  animals 
do  not  prove  much,  because  their  morbid  anatomy  diverges  so  much 
from  the  changes  found  in  human  phthisis. 

The  problem  why  the  human  adult  after  infection  with  tubercle 
bacilli  develops  phthisis,  a  disease  unknown  in  early  childhood  and 
among  the  lower  animals,  has  not  yet  been  solved  to  the  satisfaction 
of  all  who  are  entitled  to  an  opinion.  Freund,  Hart,  Bacmeister,  and 
others  believe  that  pressure  of  a  short  rib  or  an  ossified  first  costal 
cartilage  upon  the  apex  of  the  lung  is  responsible  for  the  apical  localiza- 
tion of  phthisis  (see  p.  84).  We  have,  however,  shown  that  this 
theory  does  not  explain  everything  connected  with  the  problem. 
Various  other  theories  have  been  promulgated  to  explain  the  origin 
of  human  phthisis. 

Phthisis  as  a  Disease  Acquired  during  Childhood. — During  recent 
years  the  theory  that  phthisis  is  a  late  manifestation  of  tuberculosis 

1  Die  Ausbreitung  der  Tuberkulose  im  Korper,  Marliurg,  1900. 

2  Die  Entstehung  der  menschlichen  Lungenphthise,  Berlin,  1914,  p.  35. 


PHTHISIS   AS  A   DISEASE  ACQUIRED  DURING  CHILDHOOD     105 

acquired  during  childhood  has  been  gaining  ground.  Behring/  basing 
his  opinions  on  experiments  with  guinea-pigs,  maintains  that  a  single 
infection  cannot  result  in  phthisis.  He  says  that  phthisis  is  the  result 
of  reinfection  of  a  person  who  was  already  once  infected  during 
infancy,  mainly  through  deglutition  of  milk  derived  from  tuberculous 
cows.  The  bacilli  pass  through  the  gastro-intestinal  tract  into  the 
lymphatics  where  they  remain  for  years  in  an  avirulent  or  mildly 
virulent  state,  and  in  the  adult,  as  a  result  of  some  intercurrent  affec- 
tion, they  become  again  virulent  and  cause  phthisis.  "Phthisis  is 
but  the  last  verse  of  the  song,  the  first  verse  of  which  was  sung  to  the 
infant  at  its  cradle.  "^ 

Hamburger's^  conception  of  phthisis  is  also  that  it  must  not 
necessarily  be  preceded  by  recent  infection,  but  that  it  is  rather  a 
reawakening  or  an  exacerbation  of  an  old,  "healed,"  or  latent  tuber- 
culous process.  He  points  out  that  tuberculosis  runs  a  different  course 
in  children  than  in  adults — pulmonary  phthisis  which  is  so  frequent 
in  adults  is  exceedingly  rare  in  children.  But  we  know  that  most 
people  have  passed  through  a  tuberculous  infection  during  childhood. 
Under  the  circumstances  the  inference  is  justified  that  pulmonary 
phthisis  is  invariably  preceded  by  a  tuberculous  infection  many  years 
before  its  onset. 

To  Hamburger  the  course  of  phthisis  is  similar  to  that  of  syphilis, 
with  periods  of  health  and  quiescence  or  latency,  interrupted  or  followed 
by  periods  of  acute  or  subacute  exacerbations.  The  primary  lesion 
is  inoculated  during  childhood,  before  the  individual  reaches  his  tenth 
year  of  life.  During  infancy  this  primary  focus,  if  massive  infection 
has  taken  place  or  the  resistance  is  low,  may  cause  miliary  tuberculosis, 
or  hematogenic  metastasis,  but  in  the  vast  majority  of  people  it  heals 
or  remains  dormant.  In  those  in  whom  metastatic  deposits  of 
tubercle  bacilli  are  distributed  in  various  parts  of  the  body,  secondary 
tuberculous  manifestations  make  their  appearance,  consisting  in  tuber- 
culosis of  the  glands,  bones,  joints,  meninges,  etc.  After  the  tenth 
year  the  tertiary  manifestations  are  met  with,  consisting  in  the  various 
forms  of  chronic  pulmonary  phthisis,  tuberculosis  of  the  larynx, 
tumor  albus,  certain  easels  of  joint  diseases,  of  the  kidneys,  lupus 
vulgaris,  tuberculous  iritis,  adhesive  pleurisy,  etc.  These  last  are 
practically  never  seen  in  infancy  and  early  childhood;  only  after 
the  disease  has  lasted  for  many  years  they  may  appear,  just  as  the 
late  manifestations  of  syphilis — tabes,  general  paralysis,  etc.,  are  only 
rarely  seen  in  early  youth,  although  syphilis  is  quite  frequent  at  that 
period  of  life. 

Phthisis  is  thus,  according  to  Hamburger,  an  exacerbation  of  tuber- 
culosis which  has  been  acquired  during  early  childhood  and  remained 

1  Deut.  med.  Wchnschr.,  1903,  xxix,  689;    Brit.  Med.  Jour.,  1903,  ii,  993. 

2  Einfuhriing  in  die  Lehre  von  der  Bekampfung  der  Infektionskrankheiten,  Berlin, 
1912,   p.  354. 

'  Die  Tuberkulose  des  Kindesalter,  Leipzig,  1912. 


106  .  PHTHISIOGENESIS 

latent  for  many  years  until  some  exciting  cause,  or  a  reduction  in  the 
powers  of  resistance,  has  brought  about  conditions  favorable  for  its 
development. 

Immunity  or  Allergy. — The  view  of  phthisiogenesis  which  has  been 
gaining  ground  of  late,  and  which  is  apparently  based  on  a  sound 
foundation,  has  been  formulated  by  Paul  Romer  to  the  effect  that 
phthisis  is  a  manifestation  of  immunity  against  tuberculosis  which  has 
been  acquired  by  an  infection  during  early  childhood. 

It  appears  that  the  observations  made  in  most  of  the  transmissible 
diseases  that  one  attack  renders  the  individual  immune  against  re- 
newed infection  with  the  same  virus,  hold  good  in  tuberculosis.  Beh- 
ring,  Romer,  Calmette,  Metchnikoff,  Hamburger,  and  many  others 
have  shown  that  the  mild  infections  with  tuberculosis  during  childhood 
endow  the  organism  with  a  certain  amount  of  immunity  against  further 
and  renewed  exogenic  infection  with  tubercle  bacilli,  so  that  an  indi- 
vidual with  a  healed  or  latent  lesion,  acquired  during  early  childhood, 
is  immune  to  these  microorganisms.  Repeated  infection  with  the 
same  virus  may  be  reinfection  or  superinfection.  By  superinfection 
is  understood  a  second  infection  at  a  time  when  the  lesions  produced 
by  the  first  infection  have  not  healed,  while  reinfection  implies  a  new 
infection  when  the  lesions  produced  by  the  first  have  completely 
healed.  "  Inasmuch  as  we  may  accept  as  a  great  probability  that 
in  tuberculosis  healing  in  the  strict  scientific  sense  never  occurs," 
says  Hamburger,^  "all  repeated  infections  in  tuberculosis  are  to  be 
considered  superinfections."  We  use  the  word  reinfection  because  this 
term  has  gained  extensive  currency  in  medical  literature. 

Experimental  Proofs  of  Immunity. — Experimentally  acquired  im- 
munity by  an  inoculation  of  tuberculosis  has  been  proved  to  exist 
by  the  researches  of  Koch,^  Behring,  Romer,^  Hamburger,  ^Yebb  and 
Williams,'*  Rossignol,  Krause  and  Yolk,  and  many  others.  When  a 
healthy  guinea-pig  is  inoculated  with  tubercle  bacilli  in  pure  culture, 
the  wound  closes  up  within  a  couple  of  days  and  seemingly  heals  up. 
But  about  ten  to  fourteen  days  later  there  appears  at  the  site  of  the 
inoculation  a  hard  nodule  which  soon  breaks  dowTi,  leaving  an  ulcer 
which  persists  till  the  animal  dies.  It  is  different  when  a  tuberculous 
animal  is  inoculated  with  tubercle  bacilli.  The  wound  also  heals, 
but  no  nodule  is  formed  and  a  few  days  later  the  point  of  inoculation 
becomes  indurated,  dark  in  color  all  around  the  punctured  point  to 
about  1  cm.  in  diameter.  During  the  next  few  days  the  spot  becomes 
necrotic  and  the  involved  tissues  are  shed,  leaving  a  flat  ulcerated 
area  which  usually  heals  quickly  and  permanently.  Yloreover,  while 
after  infecting  a  healthy  animal  the  regional  lymph  glands  become 
swollen,  this  does  not  occur  after  reinfection  of  a  tuberculous  animal. 

1  Med.  Klinik,  191.5,  xi,  .34. 

2  Deutsche  med.  Wohnschr.,  1891,  xvii,  101. 

^Beitr.  z.  Klinik  d.  Tuberkulose,  1910,  xvii,  287;    1912,  xxii,  301. 
^  .Jour.  Med.  Research,  1911,  xxiv,  1. 


IMMUNITY  OR  ALLERGY      .  107 

The  work  of  Romer^  and  Hamburger'  along  these  Hnes  has  recently 
changed  our  conception  of  tuberculous  infection  and  suggested  prophyl- 
actic measures  which  are  actually  revolutionary.  They  have  found 
that  reinfection  is  as  difficult  and  even  as  impossible  in  tuberculosis  as 
in  syphilis.  All  modes  of  infection  were  tried,  inoculation,  feeding 
and  inhalation  of  tubercle  bacilli  in  dust  or  spray,  and  contact  infection, 
which  are  akin  to  the  usual  modes  of  spontaneous  infection  in  human 
beings,  but  no  new  tuberculous  lesion  could  be  produced  in  tuber- 
culous animals,  while  the  healthy  controls  were  infected  and  succumbed 
to  the  disease  in  some  form.  Not  only  were  guinea-pigs  and  rabbits 
— which  are  very  susceptible — thus  tried,  but  sheep  which  are  not 
as  vulnerable  to  tubercle  bacilli,  and  also  dogs  which  are  strongly 
refractory,  and  monkeys  which  display  the  same  degree  of  suscepti- 
bility as  man.  Romer  found  that  when  a  healthy  sheep  is  infected 
with  a  certain  dose  of  tubercle  bacilli,  it  succumbs  within  eight  weeks 
to  acute  pulmonary  tuberculosis,  but  the  same  dose  is  harmless  in  a 
tuberculous  sheep.  In  monkeys  the  results  were  the  same.  Hamburger 
and  Toyofuko  have  proved  that  infected  guinea-pigs  are  not  only 
immune  to  inoculation  but  also  to  inhalation  which  is  deadly  to  healthy 
control  animals.  It  appears  from  Romer's  studies  that  this  immunity 
is  not  transmitted  by  heredity,  even  when  displayed  by  pregnant 
mothers. 

It  has  also  been  found  that  this  immunity  is  not  only  true  of  exogenic 
superinfection,  or  additional  infection  with  bacilli  of  another  strain, 
but  also  of  superinfection  with  bacilli  taken  from  their  own  lesions. 

Another  important  point  was  established  by  the  experimental 
investigations  of  Romer  and  Hamburger:  If  the  reinfecting  dose 
of  tubercle  bacilli  is  small,  perfect  immunity  is  found — the  point  of 
inoculation  heals  quite  soon.  As  a  rule,  the  immunity  is  observed 
in  animals  which  have  been  tuberculous  for  some  time,  three  or  four 
months.  But  if  the  reinfecting  dose  of  tubercle  bacilli  is  massive, 
it  soon  causes  death  of  the  animal. 

These  experimental  researches  are  well  founded,  having  been 
confirmed  by  many  workers  in  various  countries,  so  that  at  present 
they  are  as  firmly  established  as  anything  else  we  know  about  spon- 
taneous and  experimental  tuberculous  infection,  but  there  arise 
several  problems  of  immense  interest  in  our  study  of  phthisiogenesis. 
Knowing  well  that  the  vast  majority  of  human  beings  have  been 
infected  with  tubercle  bacilli  during  childhood,  even  those  who  have 
no  clinical  evidence  of  phthisis,  we  may  justly  ask,  Can  adults  be 
infected  with  tuberculosis  at  all?  The  bearings  of  this  problem  on 
prophylaxis  are  enormous.  How  does  phthisis  develop  from  the 
lesions  acquired  during  infancy  and  childhood?  Is  it  due  to  a  second 
infection  immediately  before  the  onset  of  the  disease,  or  do  the  old, 
hitherto  dormant  lesions  for  some  reason  flare  up  and  begin  to  extend  ? 

1  Beitr.  z.  Klinik  d.  Tuberkulose,  1910,  xvii,  287,  383;    1912,  xxii,  265,  301. 

2  Ibid.,  1910,  xvi,  271. 


108  PHTHISIOGENESIS 

Modes  of  Reinfection  in  Human  Beings. — A  person  who  has  once 
been  infected  with  tubercle  bacilli  may  be  reinfected  with  the  germs 
which  he  harbors  within  his  body,  or  with  bacilli  which  have  grown 
in  the  body  of  some  other  person  or  in  an  animal.  In  the  case  of 
endogenic  or  autogenic  reinfection  the  process  may  be  very  simple: 
A  softened  tuberculous  lesion  in  the  lung  is  ruptured  into  a  bronchus, 
and  during  cough  the  tuberculous  material  is  carried  along  the  bron- 
chial tree  to  some  other  part  of  the  lung  where  it  is  deposited  and, 
taking  root,  it  produces  a  new  lesion.  In  this  manner  there  may  also 
be  produced  laryngeal  and  intestinal  tuberculosis,  the  latter  from 
swallowed  sputum.  But  endogenic  reinfection  is  not  always  broncho- 
genic; it  may  also  be  hematogenic — a  tuberculous  lesion  may  break 
into  a  bloodvessel  and  then  bacilli  are  carried  to  various  parts  of  the 
body;  or  it  may  be  lymphogenic,  the  tuberculous  material  is  carried 
by  the  lymphatics,  infecting  the  lymph  glands,  etc. 

Exogenic  reinfection  should  be  very  common,  if  it  takes  place  at 
all.  The  bacilli  are  ubiquitous,  and  one  suffering  from  any  form  of 
tuberculosis  is  evidently  predisposed,  otherwise  he  would  have  escaped 
the  disease,  despite  the  first  infection.  Infection  is  exceedingly  easy, 
as  is  evident  from  the  fact  that  when  a  child  free  from  tuberculosis  is 
brought  in  contact  with  a  consumptive,  it  is  soon  infected.  Hamburger 
even  reports  a  case  where  exposure  of  an  infant  for  one  hour  was 
effective  in  infecting  it.  We  also  see  this  to  be  a  fact  in  adults:  When 
individuals  free  from  tuberculous  infection  dating  back  to  childhood, 
as  is  the  case  with  primitive  peoples,  come  into  contact  with  tuber- 
culous people,  they  are  soon  infected  and  succumb  in   a  short  time. 

Granting  these  premises,  which  are  based  on  carefully  observed 
facts,  we  may  be  able  to  study  the  problem  of  reinfection  in  man 
clinically,  even  though  the  experimental  method  is,  for  obvious  reasons, 
closed  to  us.  All  we  have  to  do  is  inquire  into  the  frequency  of  exo- 
genic and  endogenic  superinfection  and  reinfection  in  tuberculous 
patients  who  are  inmates  in  hospitals  for  consumptives;  the  frequency 
of  tuberculosis  among  those  who  are  apparently  healthy  but  live  with 
consumptives;  and  also  the  effects  of  tuberculous  infection  on  persons 
who  are  known  to  have  escaped  infection  during  childhood. 

Reinfection  in  Hospitals  for  Consumptives.— ^Clinical  experience  has 
shown  that  it  is  one  of  the  rarest  things  in  medicine  that  a  person 
should  have  one  of  the  exanthemata  twice  during  his  life.  It  has  also 
been  observed  that  in  a  ward  filled  with  cases  of  scarlet  fever,  smallpox, 
etc.,  there  is  no  danger  that  patients  suffering  from  the  more  malignant 
types  of  the  disease  should  transmit  the  virus  to  those  who  are  passing 
through  a  mild  or  abortive  attack  of  the  same  disease.  In  nearly 
all  contagious  and  infectious  diseases  we  find  that  during  the  existence 
of  the  malady  the  patient  is  immune  against  exogenic  reinfection  with 
the  virus  of  the  same  disease.  The  same  is  true  of  the  exceedingly 
chronic  transmissible  disease,  syphilis. 

The  experience  in  hospitals  harboring  large  numbers  of  consumptives 


REINFECTION  IN  HOSPITALS  FOR  CONSUMPTIVES        109 

should  give  us  information  along  these  lines  about  tuberculosis.  Here 
the  patients  have  all  the  opportunities  for  superinfection  with  bacilli 
derived  from  other  patients.  For  it  must  be  agreed  that  despite  the 
scrupulous  cleanliness  observed  at  present  in  sanatoriums  and  hospitals, 
it  is  impossible  to  avoid  droplet  infection  when  many  patients  are 
brought  into  intimate  contact.  In  fact,  when  caged  guinea-pigs  are 
kept  in  scrupulously  clean  wards  they  soon  contract  tuberculosis. 

It  has,  however,  never  been  observed  that  a  mildly  infected  patient 
living  in  an  institution  should  be  reinfected  from  one  severely  infected 
who  shares  the  ward  with  him,  even  when  the  latter  expectorates 
myriads  of  virulent  bacilli  and  offers  exceptional  opportunities  for 
droplet  infection. 

Many  non-tuberculous  patients  remain  in  sanatoriums  for  months, 
yet  it  has  not  been  observed  that  one  should  become  tuberculous 
because  of  his  sojourn  in  the  hospital.  This  is  the  reason  why  hospitals 
and  sanatoriums  do  not  separate  the  "open"  from  the  "closed" 
cases,  i.  e.,  those  who  expectorate  sputum  reeking  with  tubercle  bacilli 
from  those  who  do  not,  in  spite  of  the  fact  that  many  physicians  are 
convinced  that  droplet  infection  is  a  potent  factor  in  disseminating 
tuberculosis. 

The  hospital  staff,  including  physicians,  especially  laryngologists, 
nurses,  orderlies,  etc.,  come  in  close  contact  with  the  patients  in  sana- 
toriums and  should  become  infected  if  adults,  presumably  infected 
during  childhood,  could  be  reinfected  with  tubercle  bacilli.  But,  if 
experience  of  thousands  of  people  in  these  callings  counts  for  anything, 
they  do  not  show  a  higher  mortality  nor  morbidity  from  tuberculosis 
than  persons  in  other  occupations.  The  first  statistics  bearing  on  this 
problem  were  published  by  C.  Theodore  Williams^  who  showed  that 
long  before  the  discovery  of  the  tubercle  bacillus,  and  before  any 
precautions  were  taken  to  prevent  the  transmission  of  the  disease, 
no  case  of  infection  of  the  hospital  staff  had  been  observed.  From 
1846,  when  the  Brompton  Hospital  for  Consumptives  was  opened  in 
London,  to  1882  "statistics  showed  that  among  the  physicians, 
assistant  physicians,  hospital  clerks,  nurses  and  others,  to  the  number 
of  several  hundred,  who  had  served  in  the  hospital  (not  few  of  them 
having  lived  in  it  for  a  number  of  years  continuously),  phthisis  had 
not  been  more  common  than  it  may  be  expected  to  be  on  the  average 
among  the  civil  population  of  the  town."  In  a  later  paper  Williams^ 
brought  these  statistics  down  to  1909  and  found  that  conditions 
remained  the  same.  But  while  during  recent  years  the  improvements 
in  hygienic  conditions  and  disinfection  of  sputum  may  be  the  cause 
of  the  rarity  of  phthisis  in  the  hospital  staff',  this  cannot  be  said 
to  have  been  operative  before  1882. 

Similar  statistics  are  available  for  hospitals  in  Germany  and  France, 


1  Brit.  Med.  Jour.,  1882,  p.  618. 

2  Ibid.,  1909,  ii,  433. 


110  PHTHISIOGENESIS 

published  by  Aufrecht/  Freymuth,^  Brunon,^  Saugman/  and  others, 
and  brought  together  by  the  author^  in  a  paper  on  hospital  infection. 
Instructive  data  on  the  subject  have  been  collected  by  Saugman  from 
many  sanatoriums  in  various  countries.  He  finds  that  even  among 
laryngologist,  who  are  exposed  to  infection  more  than  any  other 
class,  the  morbidity  and  mortality  from  tuberculosis  is  less  than  would 
be  expected.  He  concludes  that  tuberculosis  is  extremely  rare  among 
those  who  are  engaged  among  consumptives;  physicians  and  laryngol- 
ogists  who  had  been  healthy  before  entering  upon  their  duties,  remain 
so.  "It  is  not  dangerous  for  healthy  adults  to  be  coughed  at  by 
patients  suffering  from  pulmonary  or  laryngeal  tuberculosis"  con- 
cludes Saugman. 

Such  facts  have  been  quoted  to  disprove  the  transmissibility  of 
tuberculosis,  but  in  the  light  of  our  present  knowledge  they  merely 
prove  that  reinfection  is  impossible. 

Marital  Phthisis. — Again,  bearing  in  mind  the  ease  with  which 
tuberculosis  is  transmitted  to  persons  who  have  not  been  infected 
previously,  it  should  be  expected  that  the  vast  majority  of  husbands 
of  tuberculous  wives,  or  healthy  wives  of  tuberculous  husbands 
should  acquire  the  disease.  This,  we  know,  is  the  case  with 
syphilis,  in  which  the  active  disease  is  almost  invariably  transmitted 
to  the  unaffected  consort,  excepting  when  the  latter  has  been  infected 
before  marriage.  But  for  a  long  time  it  has  been  a  mystery  why  phthisis 
in  both  husband  and  wife  is  very  rare  in  spite  of  the  fact  that  they 
probably  come  into  more  intimate  contact  than  even  father  and  child. 
Even  in  families  in  which  most,  or  all,  the  children  are  affected  with 
tuberculosis  it  is  exceedingly  rare  to  find  that  both  the  mother  and 
father  should  be  sick  with  the  disease.  Formerly  this  fact  was  used 
as  a  strong  argument  against  the  transmissibility  of  tuberculosis, 
but  now  we  understand  that  it  is  due  to  the  immunity  acquired  by 
an  infection  which  has  not  been  effective  in  producing  phthisis. 

For  many  years  the  writer  was  physician  to  a  charitable  society, 
having  under  his  care  annually  800  to  1000  consumptives  who  lived 
in  poverty  and  in  want,  in  overcrowded  tenements,  having  all  oppor- 
tunities to  infect  their  consorts;  in  fact  most  of  the  consumptives 
shared  their  bed  with  their  healthy  consorts.  Still,  very  few  cases  were 
met  in  which  tuberculosis  was  found  in  both  the  husband  and  the 
wife.  Widows,  whose  husbands  died  from  phthisis,  were  only  rarely 
seen  to  develop  the  disease. 

This  experience  is  not  unique.  Mongour*^  found  that  among  440 
married  couples,  in  which  one  of  the  consorts  was  sick  with  tuberculosis, 
there  were  only  16  in  which  the  partner  was  also  phthisical,  i.  e.,  4  per 

1  Munch,  mod.  Wfhnsohr.,  1908,  xlv,  158. 

•'Bc'itr.  z.  Klinik  <1.  Tulx-rkuloso,  1911,  xx,  231. 

'■'  La  tub('rfulf)sc  i)ulin()iiairo,  Pariy,  1913,  p.  59. 

^Zeitsfhr.  f.  TuhcrkuloHc,  1905,  vi,  125;    1907,  x,  221. 

5  American  Medicine,  1915,  xxi,  007. 

"  Cong.  Intern,  de  la  Tuberculose,  Paris,  1905,  i,  413. 


MARITAL  PHTHISIS  111 

cent.  Thom^  reports  of  402  couples  with  only  12,  or  3  per  cent.,  in 
which  infection  of  the  consort  had  taken  place  in  all  probabilities. 
I.  Burney  Yeo^  found  marital  phthisis  comparatively  rare,  basing 
his  deductions  on  particulars  collected  of  1055  cases  of  consumption. 
He  cites  figures  of  J.  R.  Bartlett,  Herman  Weber,  and  others  and  con- 
cludes: "Taking  these  figures  for  what  they  are  worth,  it  seems 
certain  that  the  communication  of  consumption  from  wife  to  husband, 
even  among  the  class  in  which  the  conditions  of  life  favor  to  the 
utmost  the  communication  of  contagious  disease,  is  very  rare;  while 
it  would  seem  that  communication  from  husband  to  wife  is  more 
frequent."  Pope,^  Pearson,*  Elderton,  and  Goring  have  made  careful 
statistical  studies  of  this  problem  in  England  and  arrive  at  the  con- 
clusion that  the  chances  of  tuberculosis  occurring  in  both  consorts 
are  about  the  same  as  insanity,  and  a  German  writer  has  shown  that 
cancer  in  both  consorts  is  more  apt  to  occur  than  phthisis.  In  a  recent 
statistical  study  by  Levy,^  comprising  317  married  couples  which 
lived  in  poverty,  34  per  cent,  sharing  the  bed,  possible  marital  infection 
could  be  traced  only  in  2.8  per  cent.  He  points  out  that  when  marital 
phthisis  does  occur,  it  is  characterized  by  a  favorable  course  of  the 
disease  in  the  secondary  cases,  and  soon  after  the  actively  diseased 
partner  is  removed,  the  infected  consort  recovers  his  or  her  health. 
Haupt  found  among  1553  tuberculous  couples  that  106,  or  7  per  cent., 
were  both  affected.  This  being  the  highest  percentage  recorded,  it 
is  essential  to  remember  that  it  is  exactly  the  proportion  in  which 
humanity  suffers  from  the  disease. 

Romer  mentions  that  life  insurance  companies  in  Germany,  basing 
their  action  on  statistical  experience,  do  not  reject  persons  because  of 
a  history  of  exposure  to  infection,  or  those  who  live  with  tuberculous 
consorts.  George  Florschiitz'^  in  his  work  on  insurance  selection, 
says  that  "in  medical  selection  one  must  certainly  consider  the  risk 
of  infection  when  it  is  so  evident  as  in  conjugal  intercourse,  but  in 
general  as  far  as  life  insurance  is  concerned,  one  may  regard  tuberculous 
infection  as  purely  a  matter  of  chance."  He  brings  statistics  "  showing 
that  of  1428  deaths  from  tuberculsois,  there  were  but  11  in  which 
the  husband  or  wife  of  the  deceased  were  tuberculous." 

We  have  dwelt  on  these  facts  because  they  are  very  important  points 
in  phthisiogenesis :  (1)  tuberculous  infection  can  only  occur  once; 
and  (2)  that  phthisis  evolves  only  in  persons  who  are  for  one  reason  or 
another  predisposed  to  the  disease.  Inasmuch  as  the  non-phthisical 
consort  has  already  been  infected  with  tubercle  bacilli  during  child- 
hood, all  new  opportunities  for  reinfection  by  cohabitation  with  a 

1  Zeitschr.  f.  Tuberkulose,  1905,  vii,  12. 

2  Brit.  Med.  Jour.,  June  17,  1882,  p.  895. 

'  A  Second  Study  of  Statist,  of  Pul.  Tuberc.  Marital  Infection,  London,  1911. 
■•  Tuberculosis,  Heredity  and  Environment,  London,  1912;    The  Fight  against  Tuber- 
culosis and  the  Death  Rate  from  Phthisis,  London,  1911. 
5  Beitr.  z.  KHnik  d.  Tuberkulose,  1914,  xxxii,  147. 
s  Medical  Record,  1915,  Ixxxvii,  957. 


112  PH  THISIOGENESIS 

consumptive  consort  are  of  no  avail  to  produce  phthisis.  It  is  his  or 
her  constitution  that  determines  whether  consumption  will  develop, 
and  not  the  opportunities  for  reinfection. 

Clinical  Proofs  of  Immunity  Acquired  by  Tuberculous  Infection. — 
Many  investigators  have  shown  that  tubercle  bacilli  circulate  in  the 
blood  of  a  large  proportion  of  consumptives,  yet  they  do  not  manifest 
general  or  miliary  tuberculosis,  as  would  a  priori  be  expected.  The 
only  plausible  explanation  is  that  inasmuch  as  they  have  already  a 
tuberculous  focus  in  some  part  of  the  body,  this  protects  them  against 
renewed  endogenic  or  exogenic  reinfection,  and  the  bacilli  in  the  blood 
remain  innocuous. 

A  number  of  clinical  facts,  hitherto  obscure,  can  be  explained  by 
this  acquired  immunity  of  the  tuberculous  to  tuberculosis  and  they 
confirm  the  assumption  that  the  experimentajl  data  obtained  in  animals 
hold  good  for  man.  Thus,  in  spite  of  the  fact  that  so  much  sputum 
containing  tubercle  bacilli,  passes  through  the  throat,  tonsils,  mouth, 
lips,  etc.,  tuberculosis  of  these  mucous  membranes  and  the  cervical 
glands  is  exceedingly  rare  in  adults.  Conversely,  in  former  times 
physicians  believed  that  scrofulous  children  were  immune  to  phthisis, 
and  my  observations  leads  me  to  the  conviction  that  this  is  true 
today. 

Calmette^  says :  "  Everyone  knows  that  a  local  tuberculous  suppura- 
tion occurring  in  a  person  with  pulmonary  tuberculosis  ameliorates 
the  condition  of  the  patient  and  considerably  increases  his  resistance. 
Inversely,  it  is  rare  that  patients  in  whom  pulmonary  tuberculosis 
has  had  a  rapid  development  have  been  attacked  previously  by  sup- 
puration of  the  lymph  nodes,  or  bony  or  cutaneous  tissues,  except 
in  cases  where  an  inopportune  surgical  operation  has  provoked  infec- 
tion of  the  blood.  It  is  a  well-known  fact  that  about  a  quarter 
of  the  persons  suffering  from  lupus  present  the  auscultatory  signs 
characteristic  of  pulmonary  tuberculosis,  and  that  these  generally 
develop  in  them  with  very  great  slowness;  likewise  many  lupus  patients 
live  to  advanced  age."  Marfan  also  found  that  persons  with  healed 
tuberculosis  of  the  skin  and  glands  never  become  phthisical,  and 
Piery"-^  shows  that  a  certain  number  of  children  of  tuberculous  parentage 
display  a  veritable  immunity  against  the  grave  and  acute  forms  of 
tuberculosis.  They  are  just  the  ones  who  present  the  alleged  stigmata 
of  tuberculous  heredity,  which  predisposes  according  to  some  authors. 

Mayo^'  pointed  out  that  in  Minnesota,  where  surgical  tuberculosis 
is  rife,  phthisis  is  uncommon,  and  this  has  been  observed  to  be  a  fact 
in  other  places.  Turban,  Weicher,  and  King  record  the  more  favorable 
course  of  phthisis  where  a  family  history  of  tuberculosis  is  i)resent 
and  the  same  is  the  case  where  the  individual  has  been  scrofulous. 
Clive  Riviere  is  inclined  to  attribute  the  scrofulous  manifestations, 

1  Medical  Record,  1908,  Ixxiv,  741. 

2  Lyon  Medicale,  1910,  cxv,  889. 

'  Jour.  Amer.  Med.  Assn.,  1905,  xliv,  115G. 


TUBERCULOSIS  ON   "VIRGIN  SOIL"   IN  HUMAN  BEINGS     113 

as  well  as  the  surgical  tuberculous  lesions,  to  bovine  infection,  but 
he  nevertheless  emphasizes  their  importance  as  immunizing  factors 
against  renewed  infection  with  human  bacilli. 

Experience,  experimental  as  well  as  clinical,  among  animals  has  also 
not  revealed  any  hereditary  transmission  of  specific  "predisposition" 
to  the  disease,  despite  the  fact  that  clinical  medical  treatises  keep  on 
speaking  of  "predisposition"  which  is  transmitted  from  generation 
to  generation.  Speaking  of  specific  predisposition,  Baldwin^  says: 
"Here  again  the  bovine  race  gives  a  negative  to  the  assertion  that 
tuberculous  infection  necessarily  involves  a  transmitted  weakness 
or  susceptibility.  On  the  contrary,  breeding  from  tuberculin-reacting 
cows  is  actually  practised  as  of  eugenic  value  in  preserving  the  best 
stocks.  The  well-known  Bang  system  has  been  on  trial  long  enough 
in  Denmark  to  have  demonstrated  its  value,  and  is,  I  believe,  the 
approved  method  of  procedure  in  valuable  dairies  where  tuberculosis 
is  a  serious  menace."  Harlow  Brooks  has  shown  that  the  progeny 
of  tuberculous  cows  show  no  predisposition  to  the  disease,  as  was 
already  mentioned. 

We  know  that  all  consumptives  swallow  tubercle  bacilli,  yet  tuber- 
culosis of  the  gastro-intestinal  tract  is  not  as  frequent  as  opportunities 
for  infection  would  lead  us  to  expect.  When  infection  of  these  organs 
does  take  place,  the  lesions  remain  local  without  extending  to  the 
regional  lymphatic  glands,  as  is  the  rule  with  primary  intestinal 
tuberculosis. 

Secondary  tuberculosis  of  the  skin  is  exceedingly  rare  in  consump- 
tives, although  sputum  reeking  with  tubercle  bacilli  is  very  often  care- 
lessly handled  by  them;  and  when  it  does  occur,  it  runs  a  much  milder 
course  than  lupus — primary  tuberculosis  of  the  skin.  The  well- 
known  "pathologist's  wart"  and  "butcher's  wart"  which,  although 
of  a  tuberculous  character,  are  of  no  significance,  apparently  because 
of  old  and  dormant  tuberculous  lesions  in  some  other  parts  of  the 
body  which  confer  immunity. 

Tuberculosis  on  "Virgin  Soil"  in  Human  Beings.— While  direct 
experiments  on  human  beings  are  not  available  for  obvious  reasons, 
still  some  clinical  facts  are  known  which  confirm  the  view  just  expressed. 
Bearing  in  mind  that  newborn  infants  are  free  from  tuberculosis,  no 
matter  from  what  stock  they  are  descended,  we  should  expect  that  if 
tubercle  bacilli  were  inoculated  into  infants,  the  resulting  disease 
would  run  an  acute  and  progressive  course,  just  as  is  the  case  with 
experimental  tuberculolsis  in  guinea-pigs  or  rabbits.  This  is  actually 
the  case  when  during  ritual  circumcision  among  Jews  the  wound  is 
infected  with  sputum  from  a  tuberculous  operator  (Mohel.)  The 
infant  promptly  becomes  sick  with  tuberculosis  and  the  disease  runs 
an  acute,  rapid  and  fatal  course,  the  regional  lymphatic  glands  being 
implicated.    This  is  a  drastic  contrast  to  the  mildness  of  the  "patholo- 

1  Amer.  Jour.  Med.  Sci.,  1915,  cxlix,  882. 


114  PH  THISIOGENESIS 

gist's  wart"  in  the  adult,  which  is  also  acquired  by  inoculation  of 
tubercle  bacilli  into  a  wound.  Woods  Hutchinson^  says  that  the  first 
thing  that  struck  him  on  visiting  American  Indian  children's  schools 
and  reservations  was  the  large  number  of  individuals,  both  adults  and 
children,  showing  huge  scars  in  the  neck  or  enlarged  glands;  next,  he 
found  a  strong  tendency  among  Indian  children  to  acquire  tuberculosis 
of  an  exceedingly  rapid  and  fatal  type. 

On  the  other  hand,  Baumgarten  injected  cancerous  adults,  who 
may  be  assumed  to  have  been  infected  with  tuberculosis  during  child- 
hood, with  virulent  bovine  tubercle  bacilli,  and  Klemperer  injected 
similar  microorganisms  into  tuberculous  persons,  without  any  dele- 
terious results  (see  p.  50).  These  authors  sought  to  prove  that  bovine 
tubercle  bacilli  are  harmless  to  man,  but  in  truth  they  confirmed  experi- 
mentally that  infected  individuals  are  immune  to  superinfection.  In 
infants,  tuberculosis,  when  it  causes  disease,  appears  as  a  general  dis- 
ease similar  to  typhoid  or  septicemia;  as  a  metastatic  infection  with 
deposits  of  tubercles  in  various  parts  of  the  body,  like  pyemia;  or 
as  an  acute  pneumonic  or  bronchopneumonic  process,  fatal  in  the 
vast  majority  of  cases.  The  explanation  for  this  phenomenon  is  that 
in  the  infant  there  occurs  a  primary  massive  infection  of  an  organism 
that  has  been  free  heretofore  from  the  tuberculous  virus — real  virgin 
soil.  The  same  is  true  of  primitive  peoples  who  have  never  been 
infected  with  tubercle  bacilli — when  they  are  infected  as  adults,  the 
disease  pursues  an  acute  and  fatal  course  almost  invariably. 

Phthisis  as  a  Manifestation  of  Immunity. — From  the  experimental 
and  clinical  data  arrayed  here,  it  is  clear  that  neither  infection  with 
tubercle  bacilli  nor  predisposition  is  alone  capable  of  producing 
phthisis.  To  each  one  who  has  become  phthisical,  there  are  many 
who  have  been  infected  with  tubercle  bacilli  and  remained  healthy 
in  the  clinical  sense.  In  fact,  spontaneous  infection  acquired  during 
childhood  appears  to  render  the  body  immune  against  further  and 
renewed  exogenic  infection  with  the  same  bacilli. 

It  is  also  clear  that  phthisis  occurs  only  in  individuals  who  ha\'e 
been  infected  with  tuberculosis  during  childhood,  but  have  remained 
healthy  till  adolescence.  In  other  words,  phthisis  occurs  only  in  persons 
who  have  been  immunized  by  an  earlier  infection.  In  fact,  it  is  in 
itself  a  manifestation  of  immunity',  otherwise  the  patient  would  suc- 
cumb to  acute  general  miliary  tuberculosis,  as  do  those  who  have  not 
been  immunized  by  earlier  mild  infection.  This  immunity  is  apparentl>' 
sufficient  to  protect  the  individual  under  ordinary  circumstances, 
but  under  certain  conditions  it  may  fail,  and  the  person  may  be  re- 
infected either  from  without,  the  tubercle  bacilli  being  so  ubiquitous 
that  we  can  hardly  escape  them;  or  from  within,  by  the  })roliferation 
of  the  bacilli  that  have  been  harbored  in  "healed"  or  quiescent  foci, 
through  metastasis. 

1  New  York  Med.  Jour.,  lUOT,  Ixxvi,  624. 


IMMUNITY  THROUGH  BOVINE  INFECTION  115 

Failure  of  Immunity. — Acquired  immunity  in  contagious  diseases  is 
hardly  ever  absolute — it  is  only  relative,  sufficient  for  the  ordinary 
conditions  of  life  and  failing  during  emergencies.  The  same  appears 
to  be  true  of  the  immunity  acquired  during  childhood  by  infection 
with  tubercle  bacilli.  It  protects  the  average  person  against  exogenic 
reinfection  with  tubercle  bacilli,  and  moderate  failure  of  immunity 
permitting  reinfection  does  not  result  in  general  tuberculosis,  but  only 
in  phthisis — the  most  vulnerable  organ  in  the  body  succumbs,  while 
the  others  are  still  more  or  less  protected. 

There  seems  to  be  good  evidence  to  the  effect  that  the  outcome  of 
the  infection  which  practically  everybody  passes  through  during 
childhood  depends,  in  a  large  measure,  on  the  extent  of  the  microbic 
invasion.  When  the  dose  is  small,  immunity  is  the  result,  immaterial 
whether  the  initial  lesion  has  healed  completely,  the  bacilli  being 
destroyed  and  the  lesion  cicatrized,  or  not.  When  there  remain 
calcareous  foci  containing  virulent  tubercle  bacilli,  they  remain  in- 
nocuous as  regards  their  host,  and  are  probably  an  even  better  founda- 
tion for  immunity.  But  when  the  initial  bacterial  invasion  is  massive 
it  may  cause  hematogenic  tuberculosis  of  the  glands,  bones,  or  joints 
during  childhood ;  or  when  the  resistance  is  very  low,  fatal  tuberculosis 
of  any  organ,  especially  the  lungs,  meninges,  etc.,  may  result.  But 
even  massive  infection  may  be  kept  in  check  till  adolescence  when, 
under  certain  exciting  causes,  the  lesion  flares  up  again  and  phthisis 
is  the  result. 

Immunity  through  Bovine  Infection.  —  Some  authors  have  been 
inclined  to  attribute  the  immunity  observed  in  most  adults  to  infec- 
tion during  childhood  with  the  bovine  type  of  bacilli  which  protects 
the  individual  against  superinfection  with  bacilli  of  the  human  type. 
Clive  Riviere^  even  advocates  the  immunization  of  humanity  along 
these  lines.  He  says  that  "until  human  sources  of  infection  can  be 
practically  eliminated,  or  artificial  immunization  becomes  an  ac- 
complished fact,  infection  with  the  bovine  bacillus  through  the  use 
of  a  well-mixed  milk  remains  our  best  ally  in  the  campaign  against 
tuberculosis."  We  have  seen  already  that  bovine  infection  is  fatal 
only  on  exceedingly  rare  occasions.  That  it  may  protect  against 
infection  with  the  human  type  of  bacillus  is  made  highly  probable 
by  the  rarity  of  phthisis  in  surgical  tuberculosis.  "Very  significant 
in  this  respect  also  are  the  figures  of  McNeil  for  Edinburgh  where, 
as  show^n  by  Fraser  and  Philip  Mitchell,  tuberculosis  of  bovine  origin 
is  particularly  rife.  Comparing  Edinburgh  with  Vienna  he  finds  the 
incidence  of  tubercle  infection  higher  in  the  former  for  children  up 
to  the  age  of  four  years,  and  this  in  itself  is  highly  suggestive  of  milk 
infection;  but  the  valuable  comment  on  this  is  the  fact  that  the 
mortality  from  phthisis  in  Vienna  is  nearly  three  times  as  high  as  that 
for  Edinburgh.    Indeed,  the  high  incidence  of  abdominal  tuberculosis, 

1  Brit.  Jour,  of  Tuber.,  1914,  viii,  S3. 


116  PHTHISIOGENESIS 

and  the  low  mortality  from  phthisis,  is  characteristic  of  Great  Britain 
as  a  whole  when  compared  with  other  civiHzed  countries  of  Europe, 
and  this  may  well  bear  the  interpretation  that  it  is  the  early  bovine 
infection  which  protects  against  the  inroads  of  pulmonary  tuber- 
culosis caused  by  the  human  strain  of  tubercle  bacillus." 

Nature  of  Predisposition  to  Phthisis. — Obviously,  the  evolution  of 
phthisis  does  not  depend  alone  on  the  intensity  of  the  infection  during 
childhood.  The  character  of  the  soil  invaded  by  the  bacilli  is  perhaps 
more  important.  Some  succumb  to  hematogenic  tuberculosis  even  as 
a  result  of  a  mild  infection,  harmless  to  the  average  individual,  which 
indicates  that  predisposition  was  a  stronger  factor.  In  what  this 
predisposition  consists  we  are  in  the  dark,  though  some  factors  are 
known  to  reduce  the  natural  resisting  forces  to  a  minimum.  Thus,  as 
we  have  already  shown,  certain  occupations,  especially  those  involv- 
ing the  inhalation  of  dust,  prepare  the  soil  for  the  proliferation  of  the 
bacilli  by  reducing  the  vitality  of  the  lung  locally.  Perhaps  shorten- 
ing of  the  first  rib  and  ossification  of  the  first  costal  cartilage  are 
instrumental  in  this  direction  in  some  persons. 

Failure  of  immunity  may  be  due  to  various  complex  biochemical 
changes  in  the  body  with  which  we  are  unacquainted  at  the  present 
state  of  our  knowledge.  This  is  seen  in  children  who  have  been  in- 
fected but  who  thrive  in  spite  of  it,  until  an  attack  of  measles,  whoop- 
ing-cough, etc.,  which  is  accompanied  by  a  failure  in  allergy,  as  is 
evident  from  the  negative  outcome  of  the  cutaneous  tuberculin  test 
during  the  active  stage  of  the  disease,  flares  up  the  latent  tuberculous 
focus  and  tuberculous  bronchopneumonia  results.  Other  febrile  dis- 
eases may  act  in  the  same  manner,  but  we  do  not  as  yet  know  the 
exact  nature  and  effects  of  these  biochemical  changes  in  the  body 
following  contagious  disease. 

The  nature  of  predisposition  is  the  stumbling-block  of  the  theories 
of  phthisiogenesis.  Clinical,  demographic,  and  experimental  observa- 
tions have  not  cleared  up  these  important  problems.  It  appears  that 
no  single  predisposing  factor,  nor  a  combination  of  several  factors,  will 
fit  most  cases.  As  has  been  pointed  out  by  Martins,^  the  predisposition 
of  the  individual  is,  after  all,  not  a  specific  entity,  which  is  possessed 
by  those  who  are  attacked  by  phthisis,  and  lacks  in  those  who  escape 
the  disease  despite  infection.  It  appears  to  be  a  complex  affair:  In 
each  individual  case  there  are  a  number  of  anatomical  and  physi- 
ological factors  which  may  each  alone,  or  several  in  combination, 
decide  under  certain  conditions  whether  the  person  is  to  become 
phthisical,  and  even  these  factors  are  subject  to  great  oscillations,  and 
may  combine  differently  under  different  conditions.  From  this  point 
of  view  everybody  is  predisposed  to  tuberculosis,  but  there  are  many 
important  differences  in  the  resisting  jjowers  of  different  iIldi^•idual 
persons  which  depend  on  the  number,  intensity  and  accidental  com- 

1  111  Brauer,  Schroder  and  Bluniciifeld's  Haiidbuch  d.  Tuberkulosc,  i,  395. 


ENDOGENIC  AND  EXOGENIC  REINFECTION  117 

binations  of  the  various  predisposing  factors  which,  by  themselves,  are 
influenced  by  certain  vital,  biological  oscillations  occurring  during  the 
lifetime  of  the  individual.  We  thus  have  gradations  of  predisposition 
from  the  strongest  degree  of  vulnerability  to  the  highest  degree  of 
immunity. 

Endogenic  and  Exogenic  Reinfection. — Considering  phthisis  as  a 
disease  which  develops  only  in  an  organism  which  has  been  immun- 
ized by  an  earlier  infection  which  has  left  a  latent  or  "healed"  tuber- 
culous focus  in  some  part  of  the  body,  the  problem  arises  whether 
the  flaring  up  of  the  local  lesion  in  the  lung  is  caused  by  a  new  infec- 
tion from  without  by  the  invasion  of  new  bacilli,  or  from  within  by 
metastatic  migration  of  bacilli  which  have  been  kept  dormant  for 
years  until  the  immunity  they  conferred  fails  for  some  reason. 

Experimental  findings  on  this  point  are  somewhat  conflicting.  Orth 
and  Rabinowitsch^  have  found  that  when  guinea-pigs  are  mildly 
infected  with  small  doses  of  mildly  virulent  tubercle  bacilli  which 
cause  only  local  tuberculous  changes,  the  effect  produced  is  that  a 
second  infection  with  virulent  human  bacilli  does  not  cause  the  usual 
generalized  tuberculosis,  but  pulmonary  tuberculosis  results,  bearing 
some  analogy  to  pulmonary  tuberculosis  in  human  beings.  In  rabbits, 
which  react  to  human  bacilli  in  a  manner  similar  to  that  of  man,  more 
than  guinea-pigs,  they  produced  in  this  manner  chronic  tuberculous 
lesions  in  the  lungs.  Hamburger,  Bartel,  Levy,  and  others  have 
confirmed  these  findings.  This  would  indicate  that  phthisis  is  due  to 
exogenic  superinfection. 

That  the  outbreak  of  phthisis  is  due  to  an  autogenic,  or  metastatic 
reinfection  has  been  maintained  by  Behring,  according  to  whom  the 
primary  infection  takes  place  through  the  gastro-intestinal  tract  during 
childhood,  the  bacilli  remaining  latent  till  stirred  into  activity  by  some 
exciting  cause.  But  if  this  was  the  case  we  should  expect  that  pul- 
monary tuberculosis  due  to  bovine  bacilli  would  be  very  frequent, 
considering  that  at  least  10  per  cent,  of  infections  during  childhood 
are  caused  by  this  type  of  microorganism.  As  it  is,  there  have  been 
reported  very  few  cases  of  phthisis  in  which  the  bovine  bacillus  was 
found  exclusively.  It  has  been  suggested  that  those  infected  with 
bovine  bacilli  are  immune  against  human  bacilli,  and  they  are  the  ones 
who  escape  phthisis  despite  tuberculous  infection,  but  this  would  have 
to  be  proved. 

Romer  and  Much  maintain  that  their  investigations  lead  them  to  the 
conclusion  that  reinfection  is  always  endogenic,  or  metastatic  from  exist- 
ing tuberculous  foci  within  the  body.  "We  know"  says  Much,^  "that 
a  tuberculous  organism  is  not  susceptible  to,  in  fact  it  is  immune 
against,  superinfection  from  without.  We  must  also  admit  that  when 
an  organism  is  infected  during  childhood  it  passes  through  a  precarious 
crisis,  but  it  may  survive  this  first  infection  and  remain  endowed  with 

'  Drei  Vortrage  iiber  Tuberkulose,  Berlin,  1913. 

2  In  Brauer,  Schroder  and  Blumenfeld's  Handbuch  d.  Tuberkulose,  i,  247. 


118  PHTHISIOGENESIS 

immunity.  But  during  adolescence,  when  great  demands  are  made 
upon  the  vital  forces,  the  body  may  be  overwhelmed  by  the  bacilli 
and  the  most  vulnerable  organ  in  the  body — the  lung — succumbs; 
thus  phthisis  results.  One  who  hesitates  in  accepting  these  ideas  of 
reinfection  from  within  should  only  compare  phthisis  with  syphilis." 

There  are  analogous  conditions  known  in  pathology  showing  that 
an  organism  may  harbor  virulent  bacilli  without  any  harm  to  itself. 
Thus,  the  "carriers"  of  typhoid,  diphtheria,  and  other  bacilli  may  go 
around  for  years  without  showing  any  symptoms  of  disease,  although 
they  are  a  constant  danger  to  others.  But  Texas  fever  illustrates  this 
point  even  better.  Cattle  which  survive  an  attack  remain  with  the 
living  virus  within  their  bodies,  but  are  immune  against  new  infec- 
tions, so  that  they  may  remain  in  infected  pastures  without  any  danger 
to  themselves.  But  should  they  suffer  from  any  secondary  derange- 
ment, they  may,  as  a  result,  experience  an  acute  exacerbation  of  the 
process  owing  to  sudden  proliferation  of  the  virus  which  has  been 
dormant  for  a  long  time  within  their  bodies. 

There  are  similar  clinical  phenomena  in  man.  It  is  known  that 
infection  with  the  malarial  parasite  protects  against  further  infec- 
tion with  the  same  parasite  from  external  sources,  and  for  this  rea- 
son the  adult  indigenous  individuals  in  malarial  districts  are  immune 
to  malaria,  as  was  shown  by  Koch.  In  some  cases  there  occurs  further 
infection  in  later  years,  and  the  result  is  a  cachexia,  a  sort  of  malarial 
phthisis.  But  in  such  cases  the  initial  infection  must  have  been  an 
especially  strong  and  severe  one.  In  syphilis  this  is  even  illustrated 
to  a  better  advantage.  Superinfections  are  very  difficult,  usually 
impossible;  the  integuments  and  mucous  membranes  cease  to  react 
to  the  syphilitic  virus  introduced  from  without  while  they  are  sus- 
ceptible to  their  action  from  within.  John  A.  Fordyce,^  in  a  recent 
review  of  this  subject,  cites  several  other  examples:  "Levanditi  has 
demonstrated  that  animals  suffering  with  spirillary  infection'  are 
immune  to  a  new  inoculation.  Their  serum  has  a  high  antibody  con- 
tent, but  the  blood  still  harbors  parasites  and  is  capable  of  producing 
a  fresh  infection  in  healthy  animals.  So  with  the  serum  of  guinea- 
pigs  inoculated  with  Nagana  or  Surra  trypanosomes.  This  is  trypano- 
cidal for  these  organisms  in  vitro,  but  in  vivo  they  have  acquired  an 
insensibility  to  the  trypanolytic  antibodies,  for  the  blood  and  tissue 
of  the  animals  still  contain  parasites.  The  same  is  true  of  human 
subjects  suffering  from  sleeping  sickness  in  whose  serum  trypanolytic, 
agglutinating  and  other  protective  bodies  have  been  demonstrated, 
Carrying  the  analogy  to  syphilis  we  find  that  an  individual  may  harbor 
spirochetes  for  forty  or  fifty  years,  while  his  skin  and  mucous  mem- 
branes exhibit  an  insusceptibility  to  reinoculation  under  natural  ex- 
posure. However,  as  soon  as  he  is  freed  from  his  infection  he  is  again 
in  as  susceptible  a  state  as  he  was  prior  to  his  first  attack." 

lAmer.  .Jour.  Mod.  Sri.,  1915,  cxlix,  7G1. 


SUMMARY  119 

We  have  shown  that  healed  tuberculous  lesions  contain  living  and 
virulent  tubercle  bacilli;  in  fact  even  calcified  foci  contain  them.  It 
has  even  been  questioned  whether  once  infected  with  tubercle  bacilli, 
the  virus  is  ever  absent  from  the  body.  And  for  this  reason  we  may  look 
upon  phthisis  as  produced  by  endogenic  reinfection.  Thus,  according 
to  Romer,  phthisis  is  an  acute  or  subacute  exacerbation  of  a  latent  or 
quiescent  lesion  in  the  lungs  acquired  by  massive  infection  during 
childhood,  the  bacilli  remaining  dormant  for  years,  but  when  the  im- 
munity which  they  conferred  failed  owing  to  some  intercurrent  disease, 
the  lesion  in  the  lungs  flared  up.  That  the  specific  immunity  is  not 
altogether  lacking  even  under  these  circumstances  is  evident  from  the 
fact  that  the  lesion  remains  localized  for  a  long  time  in  the  most  vul- 
nerable of  organs — the  lungs.  Phthisis  is  thus  proof  of  immunity 
against  tuberculosis.  General  miliary  tuberculosis  cannot  develop  in 
an  individual  who  has  been  immunized  by  a  previous  infection  with 
tubercle  bacilli. 

The  question  why  adults  are  not  immunized  by  mild  infections  as 
children  are,  has  not  been  explained  satisfactorily.  We  have  already 
mentioned  that  adults  hailing  from  countries  where  tuberculosis  is 
unknown  and  where  they  could  not  have  been  infected  during  child- 
hood because  of  the  lack  of  tubercle  bacilli,  upon  coming  into  cities 
and  in  contact  with  tubercle-laden  surroundings — subjected  to  primary 
tuberculous  infection — soon  succumb  to  the  acute  forms  of  phthisis, 
like  infants  or  guinea-pigs.  Much  attempted  to  explain  it  by  saying 
that  either  the  organism  of  the  child  alone  is  capable  of  evolving  a 
sufficient  quantity  of  immune  bodies;  or  we  must  assume  that  an 
adult  person  coming  from  an  environment  free  from  tuberculosis  to 
one  which  is  tubercle-laden,  freely  going  around  among  people  among 
whom  there  are  many  bacilli  carriers,  is  soon  subjected  to  massive 
infection  against  which  he  does  not  possess  sufficient  powers  of  resist- 
ance. On  the  other  hand,  the  sheltered  child  does  not  roam  around 
among  various  people  during  the  first  years  of  its  life  and  comes 
in  contact  with  only  a  few  bacilli,  as  long  as  there  is  no  active  case  of 
tuberculosis  at  home.  I  may  add  that  the  suggestion  made  above 
to  the  effect  that  the  immunization  of  humanity  during  childhood  may 
be  accomplished  by  the  bovine  type  of  bacillus,  which  is  not  as  viru- 
lent as  the  human  type,  may  be  responsible  for  this  salutary  condition. 
But  this  problem  has  not  yet  been  worked  out. 

Summary. — At  the  present  state  of  our  knowledge  the  following 
conclusions  of  Romer  are  justified.  Tuberculous  infections  occurring 
during  childhood,  so  long  as  they  are  not  acute  and  fatal  immediately, 
endow  the  organism  with  a  heightened  resistance  against  renewed 
infection  with  tubercle  bacilli.  The  immunity  thus  produced  is,  as  a 
rule,  sufficient  to  protect  the  person  against  exogenic  infection  during 
later  years.  When,  however,  extraordinary  physiological  or  patho- 
logical conditions  permit  the  bacilli  harbored  within  the  body  to  pro- 
liferate because  of  the  inadequacy  of  the  failing  immunity,  which 


120  PHTHISIOGENESIS 

becomes  incapable  of  preventing  metastatic  reinfection,  new  tubercu- 
lous foci  are  formed,  and  again  clinical  phenomena  of  disease  make 
their  appearance.  Experience  shows  that  these  metastatic  reinfections 
mostly  occur  in  individuals  who  were  subjected  to  massive  infections 
during  childhood.  The  paralytic  thorax  is  perhaps  a  local  predisposing 
factor,  although  by  itself  it  is  in  the  vast  majority  of  cases  the  result 
of  a  relatively  strong  infection  with  tubercle  bacilli  during  childhood. 


CHAPTER  VI. 
PATHOLOGY  AND  MORBID  ANATOMY. 

THE    TUBERCLE. 

Tubercle  bacilli  settling  on  susceptible  soil  offering  suitable  con- 
ditions for  their  growth,  induce  a  specific  proliferation  of  the  fixed 
elements  of  connective  tissue,  capillary,  endothelial,  and  probably 
also  of  the  epithelial  cells  af  the  air  vesicles.  Acting  as  irritants  and 
injuring  the  cells  and  the  intercellular  substances,  they  produce  a 
productive  inflammation  resulting  in  the  formation  of  a  nodule,  the 
specific  granuloma  termed  tubercle  by  Laennec. 

The  tubercle  is  best  studied  in  acute  miliary  tuberculosis,  where  it 
is  encountered  in  its  purest  form.  Throughout  the  lungs  are  scattered 
small,  hard  nodules.  They  may  be  gray  and  transparent,  or  yellowish- 
white  and  opaque.  The  transparent  tubercles  are  smaller  than  millet 
seeds,  while  the  opaque  ones  are  as  large  or  even  larger.  They  are 
larger  and  more  numerous  in  the  upper  parts  of  the  lung  where  they 
grow  better  and  more  rapidly. 

Microscopically,  the  tubercle  presents  a  characteristic  structure 
(Fig.  8).  Primarily  it  is  an  avascular  structure;  with  the  grow^th 
of  the  cells,  the  bloodvessels  and  lymphatics  in  its  neighborhood  are 
compressed  and  obliterated.  Its  most  peculiar  characteristic  is  the 
large  multicellular  unit  known  as  the  giant  cell.  In  thin  sections,  a 
fine  network,  the  reticulum,  is  seen.  The  filaments  are  derived  partly 
from  extravasated  fibrin,  partly  from  curled  fibrils  of  connective 
tissue,  and  partly  from  long,  branching,  interlacing  processes  of  the 
cells,  especially  the  giant  cells,  which  have  been  described  as  looking 
like  spider's  feet,  and  also  from  newly  formed  connective-tissue  fibrils. 

Histologically,  tubercles  are  classified  as  the  epithelioid  and  the 
round-cell  varieties,  depending  on  the  predominance  of  either  of  these 
two  types  of  cells.  The  peripheral  cells  are  arranged  concentrically; 
near  the  centre  they  are  larger,  round,  or  oval,  like  epithelial  nuclei. 
Scattered  throughout  are  to  be  seen  single  Ijonphocytes  with  small, 
round  nuclei  and,  in  the  typical  tubercle,  the  polynuclear  giant  cell 
is  located  in  the  caseated  centre.  While  the  tubercle  is  often  round, 
it  may  be  of  any  form  or  shape  and  it  usually  sends  out  branches 
connecting  it  with  the  surrounding  tissues.  Most  authors  consider 
the  round  cells  as  lymphocytes  which  have  wandered  from  the  blood- 
vessels or  lymphatics. 

The  so-called  epithelioid  cells  arise  through  the  proliferation  of  the 
connective  tissue,  and  especially  the  endothelial  cells  in  hematogenic 


122  PATHOLOGY  AND  MORBID  ANATOMY 

tuberculous  follicles.  They  divide  by  karyokinesis  and  fission  of  the 
neuclei,  and  because  the  product  is  similar  to  epithelial  elements,  it  is 
called  epithelioid.  Such  follicles  are  mostly  of  microscopic  size  and 
consist  mainly  of  this  type  of  cell.  They  proliferate  very  slowly. 
^Yith  his  theory  of  phagocytosis  ]Metchnikoff,  however,  sees  in  these 
epithelioid  cells  derivatives  of  white-blood  corpuscles,  and  inasmuch 
as  they  often  show  ameboid  movements,  they  cannot  be  anything 
else  than  white-blood  corpuscles.  It  has,  however,  been  shown  that 
these  ameboid  movements  are  no  conclusive  proof  that  they  are  of 
this  origin. 


\  .  -^s'.     ^w     ..&    ,       n 


\ 


• 


* 


m 


Fig.  S. — Microscopic  tubercle.      (Tendeloo.) 

The  Giant  Cell. — The  giant  cell  is  polynuclear,  with  a  stroma  of 
fatty  degenerated  or  even  necrotic  protoplasm.  Its  form  and  size  are 
variable.  It  may  contain  as  many  as  one  hundred  o\al,  spindle- 
shaped  nuclei  arranged  concentrically  like  a  crescent.  The  tubercle 
bacilli  are  mainly  located  in  the  giant  cells  (Fig.  S),  where  they  may 
be  seen  singly  or  in  clusters,  usually  at  the  inner  side  of  the  nuclei,  or 
between  the  latter.  They  are,  however,  lacking  in  the  centre  of  the 
protoplasm  of  mature  giant  cells;  probably  the  process  of  necrobiosis 
affects  the  bacilli  as  well  as  the  body  of  the  cell. 

The  origin  of  the  giant  cells  has  been  a  debated  subject.  Some,  like 
\Yeigert  and  Baumgarten,  state  that  the\-  are  the  results  of  karyo- 


THE   TUBERCLE 


123 


kinetic  changes  of  the  nuclei  which  retain  their  capacit}^  for  division 
while  the  protoplasm,  owing  to  the  necrobiotic  effect  of  the  tubercle 
bacilli,  does  not  divide  into  separate  cells.  In  fact,  it  is  quite  common 
to  find  in  tuberculous  foci  cells  with  degenerated  protoplasm,  while 
the  nuclei  show  an  increased  chromatin  content.  From  this  point  of 
view  the  giant  cell  is  a  degenerative  phenomenon.  On  the  other  hand, 
Metchnikoff  sees  in  the  giant  cells  one  of  the  manifestations  of  phago- 
cytosis: They  are  macrophages,  or  large  active  phagocytes,  produced 
by  the  fusion  of  many  epithelial  cells  with  the  object  of  fighting  the 
invading  enemy,  the  tubercle  bacilli,  with  united  forces.  The  part  of 
the  giant  cell  which  has  no  nuclei  is  usually  dead  because  of  the  noxious 
effects  of  the  tubercle  bacilli. 


1 


,>--?3 


"VwAif-^/ 


-,\^; 


r.ik 


Fig.  9. — Cross-section  of  tuberculous  bronchus.  The  lumen  of  the  bronchus  is 
completely  filled  with  muddy  but  quite  homogeneous  caseous  matter  and  the  mucous 
membrane  has  completely  vanished.  The  rest  of  the  bronchial  wall  is  very  rich  in  cells 
and  thickened.     The  thickening  extends  far  into  the  neighboring  alveoli.     (Ribbert.) 


Tubercle  bacilli  are  mainh'  found  in  the  giant  cells,  as  we  have 
already  mentioned,  and  also  in  the  epithelioid  cells,  while  in  the  inter- 
cellular substance  they  are  only  rarely  noted.  In  the  caseous  parts 
of  the  tubercle  the  bacilli  are  found  at  the  periphery,  while  they  are 
never  seen  in  the  centre.  In  the  caseated  giant  cells  they  are  found 
only  in  the  parts  which  have  retained  their  staining  property. 

Caseation. — The  tuberculous  follicles  are  avascular  neoformations 
and  their  vitality  is  not  durable.  No  new  bloodvessels  are  formed  in 
them,  as  is  the  case  with  most  other  new  growths.  They  are  usually 
located  in  the  alveolar  framework  whence  they  compress  the  neigh- 
boring alveoli  and  finally  obliterate  them,  and  partly  in  the  smallest 
lymph  vessels,  i.  e.,  along  the  walls  of  the  smallest  arterioles  and 
bronchioles.  In  the  arterioles  a  tuberculous  obliterative  endarteritis  is 
formed  and  this  alone,  or  in  conjunction  with  thrombotic  phenomena. 


124 


PATHOLOGY  AND  MORBID  ANATOMY 


leads  to  occlusion  of  the  vessel.  In  the  small  bronchioles  caseous 
bronchitis  may  result,  which  may,  however,  arise  primarily  and 
lead  to  peribronchial  tuberculosis  secondarily.  The  bronchi  become 
permanently  plugged  by  their  own  secretions  and  by  the  irritative 
proliferation  of  their  epithelium.  The  tuberculous  gro'^'th  compresses 
and  destroys  the  elastic  fibers,  so  that  in  the  centre  of  the  nodule  there 
are  only  fragments  of  these  tissues  and  often  not  even  that,  and  air  is 
completely  excluded. 

The  necrotic  tissue  is  thus  converted  into  a  whitish  or  muddy, 
yellowish-opaque  mass;  dry,  often  fragile,  at  times  soft  or  even  vis- 
cous in  consistency.     It  has  the  appearance  of  dry  or  soft  cheese. 


Fig.  10. — Indurated  nodule  in  pulmonary  tuberculosis.  The  solid  nodule  has  a 
dark,  caseous  centre  -ndth  irregular  lacunse.  It  consists  of  coarse  connective-tissue  fibers 
in  which  carbon  particles  are  deposited  in  some  places.  A  giant  cell  is  seen  in  the  middle 
and  to  the  right,  three  others  are  seen  to  the  left.     (Ribbert.) 

Microscopically,  the  cells  are  found  to  have  undergone  coagulation 
necrosis  or  fatty  degeneration  and  are  converted  into  a  structureless 
mass  of  detritus  which  refuses  to  stain.  At  times,  we  make  out 
between  the  remnants  of  the  cells  a  filament,  consisting  of  a  fine 
network  of  granular  fibrin,  or  true  hyaline  fibrin,  the  so-called 
"fibrinoid."  Finally,  a  stage  is  reached  when  the  debris  of  cells  and 
fibrin  become  a  homogeneous  mass  in  which  no  structure  is  seen  at 
all.     This  is  true  caseous  matter. 

Some  have  suggested  that  tuberculous  toxins  are  specifically  eft'ec- 
tive  in  causing  necrobiosis  of  the  affected  cells,  but  this  has  not  been 
proved.      It  must  be  emphasized   that  desquamation   of  epithelial 


THE   TUBERCLE  125 

cells,  necrosis,  and  caseation  are  not  specific  tuberculous  changes. 
They  are  found  also  in  various  degrees  of  intensity  in  several  other 
inflammatory  processes  in  the  lungs.  Necrosis,  especially  coagulation 
necrosis,  is  also  found  in  diphtheritic  inflammation  of  mucous  mem- 
brane, and  caseation  in  gummatous  changes.  The  caseous  gummatous 
nodule  can  hardly  be  differentiated  from  the  tuberculous. 

Calcification. — The  caseous  matter  may  become  surrounded  by  a 
layer  of  connective  tissue — encapsulated — and  then,  by  the  exclusion 
of  water,  it  becomes  inspissated  and  much  reduced  in  size.  In  time 
small  granules  of  calcium  are  deposited  until  it  becomes  altogether 
calcifled.  Small  calcified  granules  may  coalesce  into  larger  concretions 
until  finally  they  are  converted  into  a  dry,  solid,  jagged,  or  fragile 
concretion  which  looks  very  much  like  chalk.  These  concretions  often 
contain  virulent  bacilli.  In  general,  it  can  be  stated  that  it  is  never 
dissolved  or  absorbed  by  autolysis  as  is  the  case  of  other  dead  matter 
in  the  tissues.  But  caseous  matter  may  be  gradually  permeated  by 
fibrinous  tissue  and  finally  converted  into  a  solid  fibrous  scar. 

Softening. — ^Very  often  the  tubercle,  instead  of  calcifying  or  under- 
going fibrosis,  softens  as  a  result  of  the  action  of  proteolytic  enzymes 
with  which  we  are  yet  unacquainted.  In  this  case  there  develops  a 
puriform,  thin  liquid,  without  any  pus  cells  but  containing  bits  of 
cheesy  matter,  which  is  known  as  puriform  liquefaction  and  "tubercu- 
lous pus."  In  other  cases  real  pus  is  formed,  or  a  mixture  of  both 
liquids  which  is  also  known  as  tuberculous  pus. 

Sclerosis. — ^But  the  tubercle  is  not  always  destined  to  necrosis, 
caseous  degeneration,  calcification  or  liquefaction.  In  most  cases  in 
which  phthisis  does  not  develop  at  all,  or  is  checked  in  its  progress 
and  healing  finally  results,  the  cells  of  the  tuberculous  nodule  are 
converted  into  fibrous  scar  tissue  through  the  agency  of  the  proliferat- 
ing connective-tissue  cells.  These  connective-tissue  cells  are  derived 
from  two  sources:  From  the  cells  in  the  neighborhood  of  the  tubercle 
and  from  the  tubercle  itself.  While  making  autopsies  on  persons  who 
died  from  any  cause  pathologists  have  found  that  a  large  proportion 
have  scars  in  their  lungs  and  pleura,  thus  showing  that  an  enormous 
number  of  persons  have  had  tuberculosis  which  healed  spontaneously. 
These  healed  or  dormant  lesions  are  responsible  for  the  large  number 
of  persons  obviously  non-tuberculous,  yet  responding  to  the  tuberculin 
test. 

The  fate  of  the  tubercle  depends  on  the  intensity  of  the  two  processes 
of  connective-tissue  proliferation  or  sclerosis,  and  of  caseation.  In 
fact,  the  clinical  course  of  the  disease  is  mainly  influenced  by  their 
relative  intensity,  the  former  being  reparative  and  the  latter  destruc- 
tive. If  the  exudative  process  predominates  and  progresses  with 
rapidity,  the  tuberculous  focus  increases  in  size  and  clinical  signifi- 
cance; but  when  the  proliferative  process  predominates,  the  inflam- 
mation proceeds  slowly  and  may  even  terminate  in  a  cure  through 
sclerosis.     In  chronic  phthisis  the  two  processes  usually  go  hand- 


126 


PATHOLOGY  AND  MORBID  ANATOMY 


in-hand;  the  reparative,  manifesting  itself  by  the  proliferation  of 
connective-tissue  cells,  is  seen  at  the  periphery  of  the  tubercle,  while 
the  centre  caseates.  Pathologists  then  speak  of  fibrocaseous  phthisis. 
In  conglomerate  tubercles  the  central  foci  may  caseate  while  those- 
at  the  periphery  are  healing  by  sclerosis  and  thus  surround  the  lesion 
and  prevent  its  progress  by  encapsulation  of  the  cheesy  centre  which 
finally  calcifies,  as  was  already  shown. 


Fig.  11. 


-Caseous  consolidation  above.      Reel  hepatization  below.      iKa.st  and 
Runiplor.) 


Tubercles  in  the  Lung. — The  first  foci  usually  take  root  in  the 
neighborhood  of  the  apices  and  may  remain  tliere  exclusively  for  a 
long  time;  in  progressive  cases,  they  may  extend  by  the  production 
of  new  nodules.  They  usually  consist  in  a  combination  of  both  the 
productive  inflammation  in  the  form  of  nodular  formation,  and  a  pneu- 
monic process.     The  first  tubercles  are  found  as  single  and  isolated 


THE   TUBERCLE  127 

nodules  or  groups  around  the  bronchi  and  the  bronchioles,  and  at  times 
also  around  the  walls  of  the  larger  bronchi  and  the  bloodvessels — peri- 
bronchial and  perivascular  tubercles.  According  to  the  intensity  of 
the  affection  and  the  resistance  of  the  individual,  the  nodules  enlarge 
and  extend  slowly  or  rapidly  and  new  ones  appear  around  them.  Large 
conglomerations  of  tubercles  may  thus  be  formed.  In  progressive 
cases  the  tubercles  do  not  remain  separated  for  a  long  time,  but  by 
fusion  of  many  the  focus  enlarges  and  extends.  The  central  nodules 
sooner  or  later  begin  to  disintegrate  and  are  converted  into  caseous 
matter.  But  in  most  cases  a  sclerotic  process  may  be  detected  which 
limits  its  progress,  excepting  in  the  very  acute  types  of  the  disease. 

The  gross  appearance  of  the  typical  tuberculous  lesion  in  the  lung 
presents  a  very  variegated  picture.  In  fact  there  are  hardly  two  cases 
which  look  alike.  The  scar  tissue  surrounding  the  cheesy  centres,  or 
insinuating  itself  within  many  caseous  and  softened  areas,  is  a  very 
strong  substance  made  up  of  thick  fibers  and  can  be  recognized  by 
its  color.  It  is  dark  because  particles  of  carbon  derived  from  the 
inspired  air  are  deposited  in  it  and  they  cannot  be  expelled  by  expectora- 
tion because  of  their  inability  to  reach  the  bronchial  glands  owing  to 
the  fact  that  the  lymph  channels  are  occluded  or  obliterated.  It  is 
therefore  more  or  less  dark  gray  or  even  black  in  color,  which  con- 
trasts distinctly  from  the  various  other  colors  of  the  lungs.  The 
distribution  of  scar  tissue  is  variable.  In  some  cases  it  is  mainly  in  the 
centre  of  a  group  of  tubercles,  or  it  surrounds  the  caseated  masses  with 
extensive  processes.  A  black,  round  or  radiating  scar  may  enclose 
a  nodule  the  size  of  a  pea  or  even  larger,  or  several  nodules.  The  cheesy 
matter  is  dry,  and  when  old,  calcified.  This  is  very  often  found  at 
the  apex  of  clinically  healed  pulmonary  tuberculosis. 

Later  the  caseous  matter  softens  and,  when  the  degenerative  process 
extends,  reaching  and  implicating  the  bronchial  mucous  membrane, 
the  softened  debris  may  break  through  the  alveoli  or  the  bronchi. 
But  in  most  cases  sclerosis  prevents  the  spread  of  the  lesion  and  even 
encapsulates  it  with  a  more  or  less  dense  fibrous  shell.  Within  the 
capsule  the  caseous  matter  dries  up  and  finall}^  calcifies,  and  it  is  stated 
that  small  foci  may  even  be  absorbed,  though  this  is  doubtful. 

There  has  been  quite  some  discussion  as  to  the  origin  of  ulcerations 
on  the  surface  of  the  bronchial  mucous  membrane  and  in  the  paren- 
chyma of  the  lung.  Some  have  considered  these  as  the  points  at  which 
the  infecting  bacilli  have  entered  with  the  inspired  air  and  set  up  the 
disease;  that  these  ulcerations  represent  the  primary  tuberculous 
lesion.  As  far  back  as  1876  Parrot  pointed  out  that  in  all  cases 
of  tracheobronchial  adenitis  such  a  primary  lesion  may  be  found  in 
the  lung  if  carefully  searched  for.  This  is  known  among  French 
pathologists  as  la  hi  de  Parrot,  Parrot's  law.  G.  Kiiss^  has  confirmed 
Parrot's  findings  on  extensive  autopsy  material,  and  more  recently 

'  Do  hcredite  parasitaire  do  la  tuljcrculose  huniainc,  Paris,  1S98. 


128  PATHOLOGY  AND  MORBID  ANATOMY 

Anton  Ghon^  has  found  the  same  condition  while  making  numerous 
autopsies.  French  authors  refer  to  these  primary  lesions  as  chancres 
tuberculeux,  and  the  enlarged  regional  glands  which  are  almost  in- 
variably found,  as  huhons  d'emhiee. 

Others  maintain  that  there  are  many  cases  of  tracheobronchial 
adenopathy  in  which  such  a  primary  lesion  in  the  bronchioles  or 
pulmonary  parenchyma  cannot  be  discovered  at  the  autopsy.  It 
is  also  shown  that  even  when  found  it  should  not  be  concluded  in  all 
cases  that  this  ulceration  represents  the  point  of  entry  of  the  bacilli. 
They  may  be  due  to  extension  of  the  peribronchial  nodules  which, 
when  enlarging,  have  reached  the  mucous  membrane,  caseated  it 
and  produced  ulceration.  As  was  already  stated  in  Chapter  V,  the 
problem  whether  phthisis  is  of  hematogenic  or  bronchogenic  origin 
rotates  around  this  point  to  a  large  extent.  The  experiments  of 
Bacmeister  have  shown  conclusively  that  such  lesions  may  be  produced 
by  the  hematogenic  route  and  that  the  primary  lesion  is  not  commonly 
in  the  mucous  membrane.  But  this  does  not  exclude  infection  of  the 
mucous  membrane.  We  have  already  shown  that  the  bacilli  may  be 
deposited  on  the  bronchial  mucous  membrane  and  pass  through  the 
lymph  channels  into  the  subepithelial  tissue  where  they  take  root, 
without  producing  a  lesion  at  the  point  of  entry. 

Caseous  Pneumonia. — The  nodular  formations  are  not  the  only 
changes  wrought  by  the  tubercle  bacilli  in  the  lungs.  There  are  also 
seen  larger  primary  infiltrations  which  are  pneumonic  in  character; 
in  fact  these  distinguish  phthisis  from  pure  tuberculosis.  These  areas 
are  of  variable  size,  from  that  of  a  pea  to  that  of  an  egg,  or  even  larger. 
They  are  round,  oval,  leaf-shaped  or  lobular  in  arrangement  (Fig.  12) ; 
they  may  be  single  or  several  may  be  found  clustered  together.  They 
are  pale,  grayish  and  later  muddy  in  color;  at  times  they  look  like 
cheese.  They  are  found  in  rapidly  progressing  fibrinous  exudations 
which  caseate  quickly — caseous  pneumonia.  Real  lobar  caseous 
pneumonia  is  exceedingly  rare.  The  diseased  parts  are  voluminous, 
airless,  heavy,  like  in  the  hepatization  of  lobar  pneumonia. 

Microscopically,  there  is  found  an  albuminous  mass  in  which  fibrin, 
red-blood  corpuscles  and  alveolar  epithelium  may  be  discovered,  but 
the  alveolar  structure  may  still  be  made  out  at  an  early  stage.  When 
seen  in  the  early  stage  we  can  follow  the  rapidly  ensuing  process  of 
coagulation  necrosis  in  the  alveolar  septse.  Tubercle  bacilli  are  found 
in  large  numbers,  especially  at  the  periphery  of  the  cheesy  focus. 
The  final  result  is  always  expulsion  of  the  caseated  and  degenerated 
debris,  leaving  excavations,  which  will  be  discussed  later  on,  excepting 
when  the  process  involves  but  a  very  small  area,  and  some  authors 
say  that  a  cure  is  then  possible  by  absorption  of  the  caseous  matter. 

Caseous  pneumonia  cannot  always  be  differentiated  from  nodular 
tuberculous  lesions,  because  when  the  nodules  extend  rapidly,  as  they 

1  Der  prinuire  Luugeuhcrd  bci  der  Tuberkulose  der  Ender,  Berlin,  1912. 


PLATE  II 


Fig.  1 


Fig.  2 


Fig.  1. — -C,  cavity  in  the  pulmonai-y  apL'x,  /'',  interlobar  fissure.  To  the  left  of  the 
cavity  are  seen  peribronchial  nodules.    Lower  parts  are  extensively  caseated. 

Fig.  2. — ■€,  small  caseous  focus  in  the  upper  part  of  the  apex.  B,  bronchus  with 
caseated  wall.  The  rest  of  the  parenchyma  is  of  normal  air  content,  but  anthracotic 
and  showing  black  pigmentation.     (Albert  Fraenkel.) 


THE   TUBERCLE  129 

do  in  some  acute  cases,  they  consist  mainly  of  a  conglomerate  group 
of  alveoli  filled  with  exudate;  the  more  rapidly  the  process  progresses, 
the  more  they  are  coalescing  and  the  greater  the  similarity  to  caseous 
pneumonia. 

Beitzke^  points  out  the  main  differences  between  tubercle  and  case- 
ous pneumonia  as  follows:  Caseous  pneumonia  is  an  exudative  in- 
flammation, while  tubercle  is  a  productive  one.  In  the  former  there 
are  therefore  found  loose  exudate  cells  and  fibrin,  while  in  the  latter 
solid  tissue  is  found,  and  fibrin  is  almost  never  encountered.  The 
exudate  in  caseous  pneumonia  lies  in  the  lumen  of  the  alveoli,  while 
the  tubercle  is  located  in  the  interstitial  tissues.  In  caseous  pneumonia 
the  elastic  fibers  remain  intact,  while  the  granulation  tissue  of  the 
tubercle  destroys  them.  These  differences  show  the  necessity  for 
differentiation  between  the  two  processes.  But  etiologically  they 
cannot  be  separated:  Both  are  due  to  the  same  cause,  both  combine 
and  affect  the  lung  tissue,  so  that  only  the  microscope  can  decide  the 
intensity  with  which  each  is  represented  in  a  given  lesion. 

Localization  and  Fate  of  the  First  Lesion  in  the  Lung. — The  first 
lesion  cannot  be  recognized  at  autopsies  of  cases  on  old  chronic  tuber- 
culosis, and  it  cannot  be  definitely  determined  whether  the  disease 
has  arisen  by  the  hematogenic  or  aerogenic  route,  as  has  already  been 
mentioned.  It  appears,  however,  that  the  initial  lesion  heals  in  the 
vast  majority  of  cases.  It  may  also  happen  that  the  initial  lesion 
should  be  completely  or  partly  healed  in  one  lung,  while  the  second 
lung  becomes  affected  with  progressive  disease.  The  nodules  undergo 
complete  fibrous  degeneration,  become  surrounded  by  connective 
tissue  which  often  implicates  the  surrounding  overlying  pleura,  a 
cicatrix  is  formed  which  contracts  the  part  of  the  lung  affected,  re- 
sulting in  those  puckered  scars  so  often  seen  at  autopsies.  Inasmuch 
as  the  lymph  channels  are  obliterated,  the  pigment  particles  inhaled 
with  the  inspired  air  cannot  be  removed,  and  they  remain  in  the 
connective  tissue,  thus  causing  slaty  induration. 

This  mode  of  healing  is  not  the  rule.  Often  the  focus  caseates 
and  is  surrounded  by  a  fibrous  capsule;  the  caseous  centre  then 
softens,  as  has  already  been  described. 

Extension  of  the  Lesion. — The  morbid  focus  may  erode  a  blood- 
vessel and  thus  break  into  the  circulation,  causing  acute  general  miliary 
tuberculosis,  but  this  is  comparatively  rare  because  of  thrombosis 
of  the  supplying  vessels.  Usually  the  process  extends  by  the  invasion 
of  the  tissues  in  the  immediate  neighborhood  of  the  initial  tubercle. 
Even  when  some  sclerosis  takes  place,  or  the  old  tubercles  calcify, 
the  extension  may  proceed  unabated.  Conglomerate  tubercles, 
massive  infiltrations  which  are  complicated  by  pneumonic  processes 
are  thus  evolved. 

The  bacilli  spread  along  the  lymph  spaces  and  lymph  channels 

1  In  Aschoff's  Spez.  pathol.  Anatomie,  Berlin,  1913,  ii,  299. 


130 


PATHOLOGY  AND  MORBID  ANATOMY 


from  the  areas  which  have  undergone  pneumonic  changes.  This  is 
proved  by  the  fact  that  around  old  lesions  there  is  often  found  a 
crop  of  new  tubercles.  In  the  same  manner  we  explain  fresh  lesions 
in  the  neighborhood  of  old  scars  or  calcified  areas  in  the  apex.  Formerly 
it  was  thought  that  the  latter  are  caused  by  new  infections,  or  super- 
infections, but  since  we  have  learned  about  the  immunity  of  the 
tuberculous  to  new  exogenic  tuberculous  infections,  we  consider  these 
as  metastatic  endogenic  extensions  of  the  process.  These  metastatic 
tubercles  increase  in  number,  coalesce,  and  finally  caseate. 


Fig.  12. — Caseous  consolidation  in  the  upper  lobe  and  bronchiectasis  in  the  lower 
lobe.      (Kast  and  Rumpler.) 

At  times  the  extension  of  the  process  proceeds  along  the  peri- 
bronchial lymph  channels  and  the  result  is  a  lobular  arrangement  of 
the  focus,  often  looking  like  a  mulberry.  Some  of  these  lesions,  espe- 
cially when  exudation  takes  place,  simulate  the  bronchopneumonic 
picture  very  much. 

Metastatic  extension  of  the  process  may  also  occur  along  the 
bronchial  tubes  and  then  it  runs  a  rather  acute  and  progressive  course. 
^Yhen  a  necrosed  focus  reaches  the  inner  surface  df  a  larger  bronchus 
and  breaks  through  the  mucous  membrane,  the  caseated  matter  is 


THE  TUBERCLE 


131 


carried  along  the  lumen  of  the  tube  and  may  be  coughed  out.  But  at 
times  it  is  aspirated  into  the  alveoli  where  it  may  produce  a  lesion 
similar  to  that  of  the  primary  infection.  Inasmuch  as  in  such  cases 
we  deal  with  larger  numbers  of  bacilli,  they  may  be  distributed  over 
larger  areas.  Most  of  these  aspiration  infections  occur  in  the  lower 
lobes  of  the  lungs,  but  the  metastatic  infective  matter  may  be  carried 
to  the  apex  by  vigorous  cough.  These  metastatic  auto-infections 
may  produce  disseminated  tuberculosis,  but  in  the  majority  of  cases 
a  single  area  is  infected  and  the  lesion  produced  is  of  the  caseous 
pneumonic  variety,  or  indurated  nodules  result. 

Dr.  J.  Kingston  Fowler^  has  given  in  detail  an  account  of  the  usual 
course  of  the  secondary  deposits  in  chronic  or  subacute  phthisis  as  he 
found  it  while  making  numerous  autopsies.     He  found  that  the  first 


Fig.  13.- 


-Tuberculous  cavity  (a)  at  apex  of  lung,  showing  its  relation  to  a  bronchus. 
(Adami  and  McCrae.) 


deposit  of  tubercles  is  not  at  the  extreme  apex.  It  is  most  commonly 
situated  from  an  inch  to  an  inch  and  a  half  below  the  summit  of  the 
lung  and  rather  nearer  to  the  posterior  and  external  borders,  and 
spreads  backward,  this  line  of  extension  explaining  the  fact  that  the 
physical  signs  of  tubercle  are  often  first  noticed  over  the  supraspinous 
fossa.  In  front,  the  lesion  corresponds  to  the  supraclavicular  fossa 
or  to  a  spot  just  below  the  centre  of  the  upper  lobe,  about  three- 
quarters  of  an  inch  within  its  margin,  and  perhaps  separated  by  an 
inch  or  more  of  healthy  tissue.  The  second  and  less  usual  seat  of  the 
primary  lesion  is  somewhat  lower  and  more  external,  and  corresponds 
to  the  first  and  second  interspaces  at  the  outer  third  of  the  clavicle. 
The  lesion  extends  downward.  The  part  which  next  shows  tubercular 
deposit  is  the  apex  of  the  lower  lobe  (the  middle  right  lobe  being  passed 
over),  from  an  inch  to  an  inch  and  a  half  below  the  upper  and  posterior 

1  The  Localization  of  the  Lesions  of  Phthisis,  London,  1888. 


132  PATHOLOGY  AND  MORBID  ANATOMY 

extremity,  and  about  the  same  distance  from  the  posterior  border, 
a  spot  nearly  corresponding  to  the  chest  wall  opposite  the  fifth  dorsal 
spine,  midway  between  the  scapular  border  and  the  spinous  processes. 
This  lesion  tends  to  spread  backward  toward  the  posterior  border  of 
the  lung,  and  laterally  along  the  interlobar  septum.  The  extension 
in  the  lower  lobe  is  almost  always  from  above  do\\aiward  and  by 
islands  of  deposit  of  racemose  shape  with  healthy  lung  between.  The 
second  lung  is  seldom  the  seat  of  secondary  deposits  until  the  lower 
lobe  of  the  first  lung  attacked  is  implicated.  The  lesions  are  usually 
situated  in  the  same  situations  to  those  of  the  apex  of  the  opposite 
side,  but  sometimes  their  site  is  close  to  the  interlobar  septum,  midway 
between  its  upper  and  lower  extremities,  corresponding  to  the  upper 
axillary  fold.  Extension  in  the  lower  lobe  of  the  second  lung  follows 
the  course  of  the  lesions  in  the  lower  lobe  of  the  first  lung. 

Emphysema. — The  unaffected  parts  of  the  lung  in  chronic  phthisis 
often  show  emphysematous  changes;  in  fact,  occasionally  on  remov- 
ing the  lungs  from  the  thorax  after  death,  they  may  be  found  so 
voluminous  that  the  tuberculous  lesion  is  not  seen  without  a  search. 
The  surface  of  the  emphysematous  parts  of  the  lung  is  usually 
puckered  because  of  the  traction  exerted  by  fibrous  bands  and  excava- 
tions within  the  organ;  or,  in  localized  emphysema,  which  is  more 
frequent,  the  surface  shows  bullse  of  various  sizes. 

This  emphysema  is  compensatory.  When  one  lung  is  extensively 
involved  by  the  tuberculous  process,  the  other  undergoes  vicarious 
enlargement,  at  times  encroaching  beyond  the  middle  line;  when 
both  lungs  are  affected,  the  unaffected  parts  become  emphysematous. 
It  appears  that  this  is  strictly  for  the  purpose  of  enlarging  the 
alveolar  surface  of  the  parts  which  remain  intact  and  thus  increas- 
ing the  breathing  surface.  In  fact,  microscopic  examination  of  the 
emphysematous  parts  of  the  lung  shows  that  there  is  no  degenerative 
atrophy  of  the  alveolar  septse  and  bloodvessels,  as  in  true  emphysema. 
The  alveoli  are  simph^  distended. 

Cavitation. — When  the  caseated  and  softened  detritus,  affected  by 
certain  chemical  changes,  becomes  undermined  in  various  directions, 
blocks  of  dense  tissue  are  loosened  and  cast  oft',  then  expectorated, 
leaving  vacant  areas  in  the  lungs  which  communicate  with  one  or  more 
bronchi.  The  walls  may  appear  sinous,  pouchy  and  covered  with  a 
caseous  or  purulent  material  and  detritus  of  disintegrated  tissues,  or 
covered  with  a  pyogenic  membrane.  In  some  cases  they  are  smooth 
and  glittering,  all  of  which  depends  on  their  mode  of  origin. 

The  excavations  in  phthisis  may  be  single  or  multiple  and  they 
are  mostly  located  in  the  upper  parts  of  the  lungs,  the  apices.  They 
may  be  the  size  of  a  hemp  seed  to  that  of  a  fist,  and  in  rare  cases  the 
complete  lung  is  excavated,  leaving  a  thick  shell  of  the  pleura.  William 
Ewart^  pointed  out  that  excavation   is  especially   i)rone  to  attack 

1  Brit,  Med.  Jour.,  1882. 


THE   TUBERCLE  133 

definite  regions  of  the  lungs.  The  apex  of  the  lower  lohe  is  thus  affected 
at  a  date  anterior  to  the  implication  of  the  lower  parts  of  the  upper 
lobe.  The  base  and  anterior  border  of  the  lower  lobe  are  least  prone 
to  excavation,  just  as  these  parts  are  altogether  the  last  to  be  involved 
in  the  tuberculous  process. 

The  question  whether  true  bronchiectatic  cavities  may  occur  in 
phthisis  has  been  debated.  Ewart  denied  such  a  possibility,  and  when 
found,  he  considered  it  purely  secondary  to  the  undue  strain  thrown 
upon  the  spongy  structures  which  escaped  disease.  But  more  recent 
investigations  have  shown  that  they  may  be  found.  Delafield  and 
Prudden  found  them  very  frequently.  The  superficial  layer  of  an 
affected  bronchus  may  be  cast  off  while  the  process  of  caseation 
goes  on  in  the  deeper  layers.  In  fact,  cavities  may  occur  without 
the  destruction  of  the  inner  bronchial  lining.  When  the  tuberculous 
process  proceeds  slowly  and  proliferation  of  tissue  is  more  active 
than  necrosis,  the  bronchi  dilate  cylindrically  and,  because  the  more 
resisting  elements — cartilage,  elastic  fibers,  and  muscles — perish,  only 
an  unsupported,  smooth  or  slightly  ulcerated  mucous  membrane 
remains,  w^hich  yields  to  the  expiratory  pressure  of  the  air  during 
cough.  These  excavations  are  usually  cylindrical  or  round  in  shape. 
They  may  be  considered  true  bronchiectatic  cavities. 

When  multiple,  the  separating  walls  of  cavities  may  be  gradually 
destroyed  and  a  sinous  vomica  is  thus  formed.  The  large  vessels 
and  the  unaffected  bronchi  resist  the  destructive  process  for  a  long 
time  and  remain  as  cylindrical  trabeculse,  traversing  the  cavity  in 
various  directions.  These  tough  septse  and  bridles  are,  however, 
not  always  remnants  of  persisting  bronchi  and  bloodvessels.  William 
Ewart  has  shown  that  they  are  more  often  chiefly  composed  of  con- 
densed airless  lung,  representing  the  remains  of  collapsed  alveolar 
tissue  originally  separating  discrete  cavities.  When  finally  these  are 
also  destroyed,  only  ridges  and  stumps  of  fibrous  tissue  remain  within 
the  cavity,  and  also  septse  which  separate  accessory  excavations  com- 
municating with  the  main  cavity. 

Only  a  small  proportion  of  the  cavities  are  bronchiectatic  in  origin; 
the  vast  majority  arise  through  the  caseated  and  hepatized  pulmonary 
parenchyma  and  expulsion  of  the  necrotic  tissue  by  expectoration. 
They  have  irregular,  ragged  walls  on  which  there  are  attached  pieces 
of  necrotic  tissue  of  various  dimensions,  bands  separating  remnants 
of  interlobular  septse  of  the  lung.  Within  the  cavity  there  are  often 
found  some  large  necrotic  lumps  of  tissue  or  sequestra  which  are  too 
large  to  be  expelled  through  the  communicating  bronchus.  On  rare 
occasions  a  cavity  is  formed  when  a  large  part  of  caseated  pulmonary 
parenchyma  is  sequestrated  in  toto.  In  case  the  cavity  is  derived 
from  a  small  caseous  peribronchial  or  bronchopneumonic  focus,  it 
is  small,  more  or  less  circumscribed  and  round.  But  when  it  is  derived 
from  a  larger  pneumonic  process  it  is  large  from  the  start  and  irreg- 
ularlv  limited.    But  small  excavations  may  fuse,  coalesce  and  form 


134 


PATHOLOGY  AND  MORBID  ANATOMY 


large,  pouchy  cavities.  The  septse  which  separate  them  fade  away  and 
a  large,  ragged  excavation  is  formed;  its  walls  are  covered  with  a 
pyogenic  membrane,  consisting  of  granulation  tissue  and  secreting 
tuberculous  pus,  like  a  chronic  abscess.' 


Fig.  14. — Left  lung,  superior  lobe,  and  upper  part  of  lower  lobe,  the  former  containing 
a  number  of  communicating  caverns,  brought  about  bj^  tuberculous  infiltration,  casea- 
tion, and  evacuation  of  the  contents  through  the  bronchi:  ^-1,  aneurismal  dilatation  of 
an  artery  spanning  one  margin  of  a  large  cavity;  B,  communication  with  another  ca^nty; 
C,  C,  thickened  and  adherent  pleura  between  the  two  involved  lobes.  The  pleura  over 
both  lobes  is  thickened,  and  at  the  autopsy  the  cavity  had  been  obliterated  by  universal 
adhesion;  D,  the  pointer  from  the  letter  D  leads  to  a  small  group  of  tubercles  in  which 
caseation  is  just  beginning;  E,  a  fused  group  of  tubercles,  farther  advanced  than  at  D. 
(Hare.) 


William  Ewart  thus  describes  the  walls  of  tuberculous  cavities 
which  have  been  freed  from  secretions  and  debris:  Internally  the 
surface  is  lined  with  a  grayish  false  membrane,  often  of  appreciable 
thickness,  but  in  other  cases  possessing  a  little  more  substance  than 
the  bloom  of  a  fresh  fruit.  In  either  case  it  is  readily  detached  and 
exposes  a  layer  which  constitutes  the  inner  and  vascular  portion  of  the 


THE  TUBERCLE  135 

capsule,  the  outer  portion  of  which  is  purely  fibrous.  The  relative 
thickness  of  these  three  coats  varies  according  to  the  age  of  the  cavities 
and  to  the  degree  of  irritation  under  which  they  may  be  placed.  The 
chief  features  of  tuberculous  cavities  are:  (1)  Absence  of  protecting 
epithelium;  (2)  gradual  decay,  leading  to  the  formation  of  a  necrotic 
layer  (pseudomembrane) ;  (3)  gradual  fibroid  growth  from  without 
constituting  the  so-called  capsule. 

Formerly  it  was  stated  that  cavitation  implies  mixed  infection.  T. 
Mitchell  Prudden's^  experimental  investigations  have  shown  that 
injections  of  pure  cultures  of  tubercle  bacilli  into  the  trachea  of  guinea- 
pigs  and  rabbits  produced  pulmonary  infiltrations;  when  streptococci 
were  added,  cavitation  was  produced.  But  more  recent  investigations 
tend  to  show  that  tubercle  bacilli  alone  are  capable  of  producing  exca- 
vations. In  this  country  Ira  Ayer^  found  cavities  in  the  lungs  of 
rabbits  after  injecting  intratracheally  massive  doses  of  a  suspension 
of  tubercle  bacilli  containing  many  coarse  clumps.  Bacmeister's 
experiments  also  showed  that  in  animals  in  which  tuberculous  infec- 
tion produces  no  cavitation,  pressure  on  the  apex  will  produce  them 
(see  p.  87),  and  that  mixed  infection  is  not  necessary  for  the  purpose. 
The  pyogenic  microorganisms  found  in  the  walls  and  secretions  of 
tuberculous  cavities  are  now  explained  as  secondary  implantations  of 
these  organisms  after  cavitation  has  taken  place  as  a  result  of  the 
action  of  the  tubercle  bacilli. 

In  slowly  progressing  or  stationary  cases  a  wall  of  connective  tissue, 
even  of  non-tuberculous  granulation  tissue,  may  form  around  the 
excavation,  and  the  necrotic  parts  within  are  cast  off  and  expectorated, 
leaving  a  smooth  cavity.  On  the  other  hand,  in  progressive  cases, 
the  necrotic  process  digs  itself  deeper  and  deeper  into  the  paren- 
chyma and  the  cavity  keeps  on  enlarging  and  may  attain  extensive 
dimensions.  With  this  process,  non-tuberculous  infection  often 
takes  place  through  the  invasion  of  streptococci  and  staphylococci 
and  other  microorganisms  which  invade  the  walls.  Here  mixed  infec- 
tion is  frequently  very  effective  in  extending  the  diseased  area.  The 
pleural  layers  over  superficially  located  cavities  are  usually  united 
by  dense  adhesions. 

These  cavities  have  a  tendency  to  enlarge  in  the  manner  just 
described,  but  on  rare  occasions  they  may  shrink  because  of  vigorous 
sclerosis  around  the  lesion  which  causes  contraction.  It  is  more 
common  that  the  walls  should  remain  smooth  and  quiescent  for 
many  years  and,  like  a  chronic  abscess,  discharge  externally  through 
a  narrow  sinus.  But  even  caseous,  ragged  cavities  may  expel  the 
necrotic  tissue  completely  and  permit  the  proliferation  of  connective 
tissue  around  the  walls.  Healing  may  thus  result,  the  spongy  con- 
dition of  the  adjacent  lung  favoring  contraction,     But  such  a  course 


■  New  York  Med.  Jour.,  1894,  Ix,  1. 
2  Jour.  Med.  Research,  1914,  xxv,  141. 


136  PATHOLOGY  AND  MORBID  ANATOMY 

is  less  likely  to  occur  when  the  excavation  is  extensive,  owing  to 
the  surrounding  caseous  pneumonic  processes  which  usually  show  a 
tendency  to  progressive  decay. 

In  extreme  cases  in  which  the  excavations  are  extensive  and  the 
formation  of  connective  tissue  is  vigorous,  implicating  the  subpleural 
structures,  the  entire  lung  may  be  destroyed  and  reduced  to  the 
size  of  a  man's  fist.  In  these  cases  the  diaphragm  is  pulled  upward 
and  with  it  some  of  the  abdominal  viscera,  especialh'  the  liver  and 
stomach.  The  mediastinum  is  pulled  over  to  the  affected  side,  pushed 
along  by  the  unaffected  emphysematous  lung.  Complete  dextrocardia 
may  be  found  in  such  cases,  with  the  tuberculous  lesion  in  the  right 
lung;  in  left-sided  lesions  the  heart  is  often  pulled  to  the  left  and 
upward. 

Closed  Cavities. — Occasionally  ca\dties  are  found  in  the  pulmonary 
parenchyma  which  do  not  communicate  directly  with  a  bronchus, 
either  because  the  lumen  is  occluded  with  the  products  of  the  exudate, 
or  connective  tissue  has  proliferated  just  at  that  point  and  plugged 
up  the  passage  to  the  bronchus.  Such  a  closed  cavity  may  open  up 
secondarily  when  the  plug  is  removed  from  any  cause.  Perfectly 
closed  cavities  in  the  anatomical  sense  are  not  frequently  seen,  at 
any  rate,  not  as  frequently  as  clinicians  make  such  a  diagnosis. 

Hemoptysis. — ^When  the  process  of  caseation  and  softening  involves 
one  of  the  bloodvessels,  which  very  often  traverse  the  walls  of  cavities, 
ulceration  may  extend  to  the  vessel,  causing  profuse  and  fatal 
hemorrhage.  The  walls  of  the  exposed  vessel  become  thinner  and 
thinner  and  finally  erode.  Because  of  the  loss  of  support  due  to 
the  progressive  inflammatory  decay  of  the  surrounding  pulmonary 
parenchyma,  it  finally  yields  to  the  intra-arterial  blood-pressure. 

More  frequently  hemorrhage  occurs  after  the  formation  of  an 
aneurismal  dilation  of  some  branches  of  the  pulmonary  artery  travers- 
ing the  walls  of  the  cavity  (Fig.  14).  The  diseased  arterial  wall  yields 
to  the  pressure,  gives  in  first  without  rupturing  owing  to  the  withdrawal 
of  support  of  the  exposed  side,  and  a  sacculated  aneurism  results; 
rarely  a  fusiform  aneurism  results  from  the  uniform  dilation  of  the 
artery.  Douglas  Powell  points  out  that  the  fibrotic  cavities  of  old 
standing  are  more  likely  to  develop  aneurism,  and  that  aneurism  is 
more  especially  found  on  the  exposed  side  of  vessels  which  are  partly 
buried  in  indurated  tissue.  These  aneurisms  vary  in  size  from  that 
of  a  pinhead  to  that  of  a  plum;  usually  they  are  single,  but  there 
may  be  more  than  one  and,  in  rare  cases,  more  than  twenty  have  been 
found  in  one  lung. 

Because  organized  clots  and  thrombi  obliterate  the  vessel,  hemor- 
rhage is  comparati\ely  rare.  In  small  cavities  the  effused  blood  may 
by  itself  prevent  further  hemorrhage,  provided  the  communicating 
bronchus  is  temporarily  plugged,  or  is  naturally  of  a  narrow  caliber. 
But  most  cavities  are  large  and  when  a  vessel  ruptures,  hemorrhage 
of  great  violence  takes  place. 


THE   TUBERCLE  137 

Rupture  of  a  Cavity  into  the  Pleura.— When  a  rapidly  progressing 
excavation  is  located  superficially  in  the  lung  and  reaches  the  surface, 
the  pleura  may  caseate  and  rupture.  In  acute  cases  in  which  there 
is  no  time  for  the  formation  of  adhesions  between  the  pleural  layers, 
a  loss  of  continuity  in  the  latter  opens  up  a  cavity  and  permits  the 
escape  of  its  contents  as  well  as  air  into  the  pleural  cavity.  Pneumo- 
thorax is  the  result,  and  when  this  has  lasted  for  some  time,  serous, 
and  purulent  effusions — hydropneumothorax,  pyopneumothorax,  etc., 
are  formed.  These  are  exceedingly  rare  in  slowly  progressing  cases 
of  phthisis  because  adhesive  pleurisy  results  before  rupture  of  an 
excavation  takes  place.  In  old  cases  I  have  observed  that  when 
pneumothorax  does  occur  the  rupture  often  takes  place  into  the 
pleura  of  the  side  that  was  only  recently  implicated. 

Reparative  Processes. — We  have  already  spoken  of  the  process  of 
repair  that  goes  on  hand-in-hand  with  the  process  of  destruction  in 
phthisis,  and  which  is  found  to  a  certain  degree  in  all  cases  excepting 
those  of  the  most  acute  types.  Judging  by  the  large  proportion  of 
persons  who  at  the  autopsy  are  found  with  fibrous  scars  in  the  lungs 
and  pleura,  as  well  as  with  calcified  foci  in  the  parenchyma  and  glands, 
it  becomes  a  convincing  fact  that  more  tuberculous  lesions  in  the 
lungs  are  healed  than  progress  to  caseation  and  softening.  It  has 
also  been  found  that  many  cases  of  these  "healed"  tubercles  contain 
virulent  tubercle  bacilli  and  thus  remain  a  constant  source  of  danger: 
They  may  flare  up  at  any  time  and  again  begin  to  activate,  or  by 
metastasis  create  new  tuberculous  foci  in  the  adjacent  or  distant  parts 
of  the  lungs  or  other  organs. 

Tendeloo^  gives  the  following  details  about  the  reparative  processes 
in  pulmonary  tuberculosis : 

1.  Every  fibrous  focus  is  to  be  considered  as  an  old  tuberculous 
lesion. 

2.  Calcification  removes  all  danger  of  the  further  spread  of  the 
lesion.  (This  is  not  in  agreement  with  the  views  expressed  above  and 
which  are  accepted  by  most  authors.) 

3.  A  fibrous  capsule  separates  quite  effectively  its  caseous  contents 
from  the  rest  of  the  parenchyma  of  the  lung,  and  the  process  may 
remain  quiescent  for  a  long  time.  As  long  as  there  remains  caseous 
matter  within  the  capsule,  or  non-fibrous  tuberculous  tissue,  there  is 
always  danger  that  the  caseous  focus  may  extend  beyond  the  fibrous 
capsule,  and  also  that  the  decay  of  the  latter  may  favor  a  further  exten- 
sion of  the  tuberculous  process  by  growth  and  metastasis.  As  long  as 
the  bacilli  remain  virulent  in  the  lesion,  and  there  are  connections 
between  the  contents  of  the  focus  and  the  surrounding  pulmonary 
parenchyma  through  lymph  spaces,  they  can  grow  under  certain 
circumstances  and  induce  pathological  changes  in  other  parts  of  the 
lung.  On  the  other  hand,  a  fibrous  capsule  interferes  with  medication 
reaching  the  lesion. 

1  In  Brauer,  Schroder  and  Blumenfeld's  Handbuch  der  Tuberkulose,  1915,  i,  98. 


138  PATHOLOGY  AND  MORBID  ANATOMY 

4.  A  fibrous  capsule  has  the  same  significance  for  an  excavation. 
But  in  this  case  other  dangers  are  added:  As  long  as  the  cavities 
contain  caseous  matter,  bronchogenic  metastasis  is  threatening 
because  there  are  always  virulent  bacilli  in  the  caseous  matter.  The 
dangers  of  softening  are  greater  in  excavations  communicating  with 
the  bronchi  because  the  air  has  free  access  to  their  contents  and  may 
bring  in  other  microorganisms,  thus  causing  mixed  infections. 

5.  Healing  of  a  cavity  is  possible  when  it  is  cleared  of  its  contents 
and  the  walls  granulate.  Small  vomicae  may  heal  w^hen  their  contents 
are  evacuated  and  the  walls  shrink.  In  more  extensive  excavations 
there  always  remains  some  vacant  space.  When  no  open  lesion 
remains,  the  elastic  fibers  and  bacilli  disappear  from  the  sputum. 

Ewart  points  out  that  whereas  in  other  organs  the  obliteration  of 
abnormal  spaces  is  effected  by  free  granulations  arising  from  the 
bottom  of  the  cavity,  surface  granulations  are  practically  absent 
from  tuberculous  excavations.  Still,  he  holds  that,  if  freely  drained, 
they  may  granulate  successfully  and  the  walls  finally  adhere.  This 
is  in  agreement  with  the  more  recent  views  of  Tendeloo.  But  this  is 
more  likely  to  be  seen  in  small  vomicae,  while  in  the  large  ones  the 
air  and  fluid  contents  offer  obstacles  to  perfect  contact  of  the  surfaces. 

In  general,  we  may  consider  the  productive  tissue  changes  as  salu- 
tary, while  the  degenerative — caseation  and  softening — as  phenomena 
lurking  with  dangers.  Still,  even  in  the  latter  healing  is  possible 
through  calcification  or  the  removal  of  the  products  of  tissue  disinte- 
gration from  the  air  passages.  It  is  doubtful  whether  caseous  matter 
can  be  absorbed,  though  some  insist  that  this  is  possible.  Exudative 
tuberculosis  may  terminate  favorably  or  unfavorably,  according  to 
its  progress  along  the  lines  of  absorption,  or  in  other  forms,  casea- 
tion and  softening,  and  elimination  with  the  expectoration  or  by 
calcification. 

It  thus  appears  that  even  extensive  tuberculosis  may  become  quies- 
cent, although  we  cannot  speak  of  healing  and  restitutio  ad  integrum 
in  the  anatomical  sense.  It  must  always  be  borne  in  mind  in  this 
connection  that  the  anatomical  changes  are  not  the  only  ones  which 
decide  the  outcome  of  the  disease  in  most  cases. 

Pathological  Changes  in  Other  Organs. — The  glands,  especially 
those  in  the  thorax — the  bronchial,  tracheal  and  mediastinal — and 
of  the  mesentery  are  very  often  affected  in  children  and  adults  who 
suft'er  from  phthisis,  more  often  than  is  generally  appreciated.  In 
fact,  it  may  be  stated  that  the  tracheobronchial  glands  are  aft'ected 
in  nearly  every  case  of  phthisis.  On  careful  and  painstaking  search 
small,  microscopic  tuberculous  foci  are  often  found  in  apparently 
unafi'ected  glands;  but  the  majority  are  swollen,  enlarged  and  many 
are  softened  while  others  are  calcified.  In  children  these  tuberculous 
glands  very  often  give  no  clinical  indication  of  their  implication;  in 
fact,  it  is  at  times  difficult  to  discover  any  changes  in  the  bronchi 
and  parenchyma  on  cursory  examination  at  the  autopsy.     Still,  these 


THE  TUBERCLE 


139 


glands  are  frequently  a  source  of  trouble,  not  only  in  causing  symp- 
toms of  tracheobronchial  adenopathy,  but  also  because  these  condi- 
tions are  to  be  considered  the  forerunners  of  phthisis  in  the  adult, 
though  some  look  upon  them  as  possible  immunizing  agents  against 
reinfection  in  later  life. 

By  pressure  these  enlarged  glands  may  cause  stenosis  of  the  main 
bronchus  in  children,  while  in  adults  it  is  less  likely  to  occur  because 


Fig.  15. — Primary  caseous  focus  in  the  left  upper  lobe  with  miliary  tubercles  in  its 
vicinity.  Caseation  of  the  regional  lymph  nodes  of  the  left  upper  lobe.  Caseation  of 
the  upper  tracheobronchial  lymph  nodes.  Acute  miliary  tubercles  in  the  lower  tracheo- 
bronchial lymph  nodes.  Over  both  lungs  disseminated  tubercles  are  to  be  seen.  The 
upper  tracheobronchial  and  bronchopulmonary  lymph  nodes  in  the  right  side  are  free 
from  pathological  changes.     (Anton  Ghon.) 

the  bronchi  are  firmer.  But  the  smaller  bronchi  may  be  compressed 
in  adults  as  well  as  in  children.  In  the  latter,  suppurating  glands 
at  times  perforate  the  trachea,  bronchi,  pericardium,  or  esophagus, 
causing  sudden  death,  tuberculous  bronchopneumonia,  etc. 

The  mesenteric  glands  are  only  rarely  affected  in  adults,  even  in 
those  who  have  tuberculous  ulcerations  of  the  intestines,  but  in 
children  they  are  often  found  to  be  the  seat  of  tuberculous  changes, 
particularly  with  bacilli  of  the  bovine  type. 


140 


PATHOLOGY  AND  MORBID  ANATOMY 


The  Larynx, — The  larynx  shows  tuberculous  changes  in  at  least 
one-third  of  cases  of  phthisis.  Proliferative  and  caseous,  as  well  as 
ulcerative,  lesions  are  found.    These  infections  are  usually  secondary 


,  „„,-,"'-. '?'N^'  - 


C'^f^ 


Fig.  16. — Tuberculous  pleural  adhesion.  At  the  lower  part  of  the  drawing  is  to  be 
noted  that  the  subcostal  cellular  tissue  is  very  much  reduced  in  quantity.  Above  it 
the  new  membrane  is  developed  at  the  expense  of  the  visceral  pleura  and  shows  a  layer 
of  tuberculous  follicles.  The  fibrous  tissue  gradually  extending  upward  and  coming  in 
contact  with  the  lung  without  any  sharp  line  of  demarcation  between  them,  is  already 
old,  well  organized  in  parallel  bundles  and  passed  by  numerous  bloodvessels.  (Chante- 
messe  and  Courcoux.) 

to  tuberculosis  in  the  lungs;  primary  tuberculosis  of  the  larynx  is 
exceedingly  rare;  in  fact,  some  authors  deny  that  it  exer  occurs. 
In  many  cases  of  laryngeal  tuberculosis  the  trachea  is  also  the  seat 
of  specific  ulcerations. 


THE  TUBERCLE 


141 


The  Pleura. — The  pleura  is  implicated  in  nearly  every  case  of  phthisis. 
A  large  proportion  of  cases  are  preceded  by  pleurisy,  moist  or  dry, 
but  even  then  it  is  usually  secondary  to  extension  of  some  small 
lesion  in  the  lung.  Pleural  adhesions  are  found  at  the  autopsy  in 
nearly  all  fatal  cases  of  phthisis,  excepting  those  running  an  exceed- 
ingly acute  course.  In  some  cases  they  are  so  dense  and  compact 
that  it  is  difficult  or  impossible  to  remove  the  lungs  without  injuring 
the  pleura.  Sometimes  the  pleura  is  thickened  all  over;  in  many 
only  partly,  especially  over  the  seat  of  the  main  lesions,  and  also 
at  the  base  where  thickening  of  the  diaphragmatic  pleura  is  not  uncom- 
mon with  resulting  elevation  of  the  diaphragm.  Many  fibrous  bands 
are  often  seen  extending  from  the  pleura  into  the  parenchyma  of  the 
lung.  The  adhesions  may  be  lax  and  easily  separated,  but  in  many 
cases  they  are  dense,  and  when  extensive  the  thick  pleura  may  sur- 
round the  lung  like  a  shell.     On  rare  occasions  the  pleura  is  even 


Fig.  17 


Fig.  18 


Fig.  19 


Figs.  17,  18,  and  19. — Tuberculous  ulcerations  of  the  intestines.     (Tendeloo.) 


found  calcified  in  places,  or  very  extensively.  Very  frequently  thick- 
ening of  the  pleura  between  the  lobes  of  the  lung  is  found.  All  these 
adhesions  are  great  hindrances  to  the  induction  of  artificial  pneumo- 
thorax for  therapeutic  purposes.  On  the  other  hand,  they  prevent 
the  occurrence  of  spontaneous  pneumothorax  through  rupture  of 
the  visceral  pleura  over  the  site  of  superficially  located  pulmonary 
lesions,  and  when  pneumothorax  does  occur,  it  is  only  localized.  Sero- 
fibrinous pleurisy  is  quite  frequent  and,  in  fatal  cases,  exudations 
occur  in  a  large  proportion  shortly  before  death. 

The  Intestines. — The  intestines  are  only  rarely  the  seat  of  primary 
tuberculosis.  In  children  it  has  been  found  between  30  and  50  per 
cent,,  and  in  adults  Orth  and  Henke  found  it  in  3  to  5  per  cent,  of  all 
autopsies.  But  in  phthisis  they  are  secondarily  aft'ected  to  the  extent 
of  90  per  cent,  of  cases,  according  to  some  authors.  Some  of  the 
anatomical   changes  are  merely  tuberculous  nodules,   but  in  most 


142  PATHOLOGY  AXD  MORBID  ANATOMY 

there  are  found  round  ulcerations  of  the  mucous  membrane  of  the 
ileus  and  colon,  especially  of  the  ascending  colon  (Fig.  17).  These 
ulcers  heal  but  rarely,  though  occasionally  there  is  encountered  a 
case  of  stricture  of  the  intestine  due  to  a  contracted  scar  resulting 
from  a  tuberculous  ulcer.  On  the  other  hand,  these  ulcers  may  per- 
forate into  the  peritoneal  cavity  with  the  usual  results  of  these 
accidents.  Ischiorectal  abscesses  are  very  frequent  in  phthisical 
patients. 

Amyloid  Degeneration.  —  The  tuberculous  toxemia  also  causes 
changes  in  various  other  organs  which,  though  not  essentially  tuber- 
culous, yet  are  more  or  less  characteristic.  Amyloid  degeneration 
occurs  mostly  in  chronic  cases  of  mixed  infection.  The  amyloid 
material  is  deposited  in  the  walls  of  the  capillaries  outside  of  the 
endothelium,  and  pressing  upon  the  lumen  of  the  vessels,  as  well  as 
the  cells  of  the  organ,  prevents  the  nutrition  of  the  parenchyma. 
The  result  is  fatty  degeneration  and  atrophy  of  the  organ.  We  are 
in  the  dark  as  to  the  origin  of  this  material.  The  liver,  spleen, 
kidneys  and  intestines  are  most  frequently  affected.  Fatty  degenera- 
tion of  the  liver  is  very  frequent. 

The  Heart. — In  the  heart  fatty  degeneration  is  usually  found  in 
persons  who  succumb  to  phthisis.  It  is  usualh'  small,  weak  and 
atrophic,  as  are  the  rest  of  the  muscles  of  the  body.  Hypertrophy  of 
the  right  heart  may  be  seen  in  cases  of  extensive  shrinkage  of  the 
lung  with  pleural  adhesions.  Endocarditis  verrucosa  is  also  very 
frequent,  but  this  is  due  to  streptococci. 

The  Muscles. — The  muscles  are  pale  or  brown,  atrophied  and 
poor  in  fat.  Microscopic  examinations  show  brown  atrophy,  fatty 
degeneration  and  other  degenerative  changes.  It  appears  that  the 
diminution  in  the  volume  of  the  muscles  is  due  to  an  atrophy  in  each 
individual  muscle  fiber,  and  not  to  dimmution  in  their  number. 


CHAPTER  VII. 

SYMPTOMATOLOGY  OF  PHTHISIS— HISTORY  OF  THE 

PATIENT. 

.  We  have  seen  that  mfection  with  tubercle  bacilh  does  hot  invari- 
ably result  in  tuberculous  disease.  Phthisis  implies  a  preexisting 
infection,  but  the  latter  may  take  place  without  any  subsequent 
clinical  manifestation  of  disease.  The  diagnosis  of  tuberculous  infec- 
tion is  a  simple  matter.  The  application  of  the  cutaneous  tuberculin 
test  tells  the  story  promptly,  easily,  and  unequivocally.  The  chances 
of  error  are  insignificant  and  may  be  disregarded. 

But  a  positive  tuberculin  reaction,  found  in  over  90  per  cent,  of 
humanity,  as  we  have  seen  above,  is  by  no  means  proof  that  the 
individual  suffers  from  any  disease  or  needs  general  or  special  treat- 
ment. It  only  shows  that  the  individual  has  been  infected  with 
tubercle  bacilli  at  some  period  of  his  or  her  life.  The  infection  may 
not  have  done  any  harm.  In  fact,  we  have  seen  that  in  all  probabili- 
ties it  has  immunized  him  against  a  new  massive  infection,  which  is 
difficult  to  avoid  and  which  might  have  produced  acute  and  progressive 
disease,  had  it  taken  root  on  virgin  soil. 

What  we  aim  at  in  our  practice  is  discovering  not  only  tuberculous 
infection,  but  tuberculous  disease.  At  any  rate  this  is  what  the 
patient  wants  to  find  out :  Whether  he  suffers  as  a  result  of  the  infec- 
tion with  tubercle  bacilli  and  whether  any  treatment  is  necessary  to 
save  or  prolong  his  life.  This  information  can  only  be  given  after  a 
careful  and  painstaking  inquiry  into  the  patient's  history,  the  symp- 
toms he  suffers  from  and  the  physical  signs  elicited  by  an  examination 
of  his  chest  and  other  parts  of  his  body,  and  applying  some  or  all  the 
clinical  diagnostic  methods  which  have  been  the  achievement  of 
medicine  during  the  past  couple  of  generations. 

Hazards  of  Hasty  Diagnosis. — ^Realizing  that  the  patient's  chances 
of  recovery  are  greatest  when  the  disease  is  recognized  and  treated 
at  its  very  mcipiency,  there  has  been  a  strong  tendency  during  recent 
years  to  treat  every  "suspect"  as  one  who  is  actively  tuberculous 
until  time  and  observation  prove  the  contrary.  This  advice  has 
been  given  by  many  writers  on  the  subject  and  followed  by  numerous 
physicians.  As  a  result  many  innocent  persons  have  been  banished 
to  sanatoriums  or  to  distant  climatic  resorts;  many  children  have 
been  deprived  of  an  education,  many  workmen  induced  to  leave  their 
employment,  many  men  of  affairs  to  neglect  their  business.     To  be 


144  SYMPTOMATOLOGY  OF  PHTHISIS 

sure,  many  of  these  non-tuberculous  individuals — "suspects" — have 
been  fatigued  and  debilitated  and  needed  a  rest,  and  the  error  in  diag- 
nosis has  rather  benefited  them.  But  with  others  things  have  been 
different.  Many  a  person  known  to  the  writer  has  been  trying  to 
remove  the  stigma  of  tuberculosis  without  avail;  and  tuberculosis  is 
a  stigma  at  present,  despite  our  teachings  that  a  patient  who  has 
common-sense  and  decency  is  as  good  and  as  harmless  as  any  other 
person. 

We  often  meet  with  people  who  had  spent  some  few  months  in  a 
sanatorium — from  all  mdications  they  could  have  gotten  along  very 
well  without  it — and  ever  since  they  live  in  constant  dread  lest  it 
will  be  found  out  that  they  had  been  "consumptives."  I  have  known 
persons  who  have  lost  their  jobs  because  some  patient  who  knew  them 
in  an  institution  "gave  them  away." 

A  hasty  diagnosis  among  the  poor  and  moderately  well-to-do — 
from  which  classes  the  bulk  of  phthisical  patients  are  being  recruited 
— works  even  more  havoc  at  times.  The  results  of  the  maxim :  "  Treat 
everyone  for  tuberculosis  till  he  proves  to  you  that  he  is  not "  can 
be  seen  in  a  city  like  New  York  where  numerous  individuals  attend 
tuberculosis  clinics  for  months,  even  for  years,  or  go  from  one  insti- 
tution to  another  for  years,  though  they  fail  to  present  any  reliable 
symptoms  of  active  phthisis.  I  have  w^itnessed  the  autopsy  on  the 
body  of  a  woman  who  remained  twenty-six  years  continuously  in  an 
institution;  about  one-half  the  time  in  a  sanatorium,  the  other  half 
in  a  hospital  for  advanced  consumptives,  where  she  finally  died  from 
pneumonia.  Careful  examination  of  the  viscera  failed  to  disclose 
an  active  tuberculous  lesion.  I  calculated  that  the  community  spent, 
or  wasted,  over  ten  thousand  dollars  on  this  woman,  not  including 
the  loss  owing  to  her  idleness.  We  may  further  mention  that  during 
the  twenty-six  years  she  kept  out  of  the  institution  at  least  forty 
patients  with  active  disease  who  might  have  benefited  by  the  treatment. 

Many  communities  keep  on  spending  considerable  sums  of  money 
on  the  maintenance  of  patients  who  could  be  cared  for  in  their 
homes  at  a  lesser  cost,  or  keep  them  from  work  merely  because  of 
a  suspicion  that  they  are  tviberculous.  Others  break  up  their 
homes,  commit  their  children  to  asylums  because  of  a  hasty  diagnosis 
of  incipient  tuberculosis  based  on  some  indefinite  symptoms  and 
physical  signs.  It  was  found  in  Germany  that  some  patients,  passed 
for  admission  to  sanatoriums  because  of  incipient  tuberculosis,  were 
fit  for  active  military  service  during  the  war.  Fifty  per  cent,  of 
patients  in  one  of  our  largest  municipal  sanatoriums  have  negative 
sputum;  that  this  is  an  indication  that  many  are  non-tuberculous 
will  be  agreed  to  by  everyone  who  has  any  experience  with  tuber- 
culosis. With  the  antiformin  method  of  sputum  examination  at  most 
10  per  cent,  of  active  cases  are  found  not  expectorating  bacilli. 

There  appears  to  manifest  itself  a  reaction  against  the  eager  chase 
for   "incipient"   cases  which  may  swell   the  favorable  statistics  of 


PRINCIPLES  IN   THE  DIAGNOSIS  OF  ACTIVE  PHTHISIS     145 

sanatoriums.  Authoritative  writers  now  state  emphatically  that 
indefinite  physical  signs  should  not  be  relied  on,  and  urge  that  only 
constitutional  symptoms  of  toxemia  be  taken  as  criteria  for  active 
disease.  Edward  O.  Otis^  questions  the  wisdom  of  relying  on  "the 
presence  of  certain  physical  signs,  definite  or  indefinite,  with  no 
symptoms  of  bacterial  toxemia  which  are  interpreted  to  mean  active 
tuberculosis,  and  the  patient  exliibiting  such  signs  is  accordingly 
removed  from  his  family  and  employment  and  consigned  to  a  sana- 
torium, where  there  is  at  least  some  risk  that  he  may  receive  a  new 
and  active  infection.  Whereas  the  individual  was  in  no  way  ill,  and 
probably  never  would  have  developed  active  clinical  tuberculosis." 

A  hasty  diagnosis  is  as  dangerous  as  neglect  to  recognize  active  and 
progressive  disease.  Delay  does  not  mean  sure  death  of  the  patient; 
if  he  is  kept  under  careful  observation  we  cannot  be  too  late  in  making 
a  positive  diagnosis.  The  acute  and  progressive  cases  will  manifest 
themselves  very  soon,  and  delay  does  not  count  because  treatment 
in  these  cases  is,  as  a  rule,  not  very  effective.  In  the  slow,  sluggish 
cases  the  delay  of  a  few  weeks  hardly  ever  makes  any  difference 
in  the  ultimate  outcome.  But  pronouncing  a  patient  phthisical  when, 
in  fact,  he  has  no  symptoms  of  active  disease,  is  often  followed  by 
disastrous  results  to  the  patient  as  well  as  to  those  depending  on  him, 
and  to  the  community  which  is  charged  with  caring  for  its  tuberculous 
dependents.  It  may  be  said  without  fear  of  meeting  contradiction 
from  competent  sources  that  an  incipient  case  in  the  full  sense  of  the 
word  does  not  always  mean  a  curable  case,  or  even  a  favorable  case. 
Many  cases  justly  classed  as  incipient  have  a  worse  prognosis  than 
those  considered  "far  advanced"  in  the  conventional  classification 
of  the  disease. 

Elementary  Principles  in  the  Diagnosis  of  Active  Phthisis. — Active 
tuberculosis,  or  phthisis,  manifests  itself  invariably  by  symptoms  of 
bacterial  intoxication.  If  there  are  no  symptoms  of  constitutional 
toxemia,  the  patient  may  have  been  infected  with  tubercle  bacilli — 
and  who  has  not  been? — but  he  is  not  sick  with  a  disease  which  needs 
special  treatment,  costly  to  the  community,  and  often  ruinous  to  the 
patient  and  his  family.  Nor  must  the  patient  be  isolated  from  his 
family,  and  hospitalized  to  prevent  the  dissemination  of  a  disease 
which  he  does  not  have.  This  is  a  point  which  must  always  be  borne 
in  mind  before  a  patient  is  told  that  he  suffers  from  incipient  phthisis. 

There  is  hardly  a  conscientious  physician  who  is  not  skilled  in  making 
a  diagnosis  of  incipient  phthisis  from  the  constitutional  symptoms, 
even  though  he  may  have  to  leave  the  localization  of  the  lesion  to 
some  virtuoso  in  physical  diagnosis.  There  is  no  active  phthisis 
without  fever,  cough,  tachycardia,  languor,  nightsweats,  hemoptysis, 
etc.  Some  or  all  of  these  symptoms  are  found  soon  after  the  patient 
becomes  actively  phthisical. 

1  New  Orleans  Med.  and  Surg.  Jour.,  1914,  Ixvii,  311. 
10 


146  SYMPTOMATOLOGY  OF  PHTHISIS 

If  these  elementary  points  were  borne  in  mind  by  physicians,  the 
number  of  mistakes  of  omission  and  commission  would  be  reduced 
to  a  minimum.  In  fact,  if  the  propaganda  made  so  assiduously, 
aggressively  and,  within  certain  limits,  justly,  that  to  be  cured, 
tuberculosis  must  be  discovered  in  its  incipiency,  would  have  insisted 
emphatically  on  the  symptomatology  of  the  disease  which  can  be 
observed  and  properly  interpreted  by  every  practising  physician,  all 
cases  coming  under  the  observation  of  physicians  would  be  detected 
in  proper  time.  It  is  wrong  to  blame  the  general  practitioner  for  the 
large  proportion  of  cases  which  are  diagnosed  rather  late,  after  he  has 
been  taught  that  certain  indefinite  physical  signs  may  mean  phthisis, 
and  just  as  often  may  mean  nothing.  In  fact,  the  general  practitioner 
may  retort  by  saying  that  the  large  proportion  of  non-tuberculous 
cases  admitted  and  kept  in  sanatoriums,  as  well  as  the  large  number 
of  patients  "cured"  within  two  or  three  months  in  the  institutions, 
prove  conclusively  that  the  specialists  are  no  less  fallible  in  this 
regard. 

Natural  Method  of  Arriving  at  a  Diagnosis. — While  in  the  practice 
of  medicine  we  must  often  resort  to  the  deductive  method  of  reasoning 
when  attempting  to  unravel  an  obscure  case,  yet  in  our  attempts 
at  ascertaining  the  presence  or  absence  of  active  phthisis,  we  are  on 
safer  ground  when  applying  the  inductive  method.  We  must  first 
ascertain  the  individual  symptoms  and  credit  each  with  its  true  merit. 
In  other  words,  all  the  morbid  phenomena  must  be  accurately  observed ; 
all  the  material  facts  are  to  be  carefully  inquired  into;  and,  what  is 
of  most  importance,  the  interpretation  of  the  collected  facts  must  be 
correct  and  in  agreement  as  regards  their  relation  one  to  another,  and 
to  the  probable  causes  which  may  underlie  the  process. 

To  do  this  rationally,  we  must  carefully  observe  the  appearance  of 
the  patient,  go  into  details  about  the  symptoms  which  urged  him  to 
seek  medical  advice  and  also  inquire  into  such  subjective  symptoms 
as  the  average  patient  is  not  likely  to  note  unless  his  attention  is 
drawn  to  them.  When  all  these  data  have  been  carefully  gathered 
and  properly  evaluated,  a  physical  examination  is  made  to  ascertain 
the  objective  signs  of  the  disease,  as  well  as  an  evaluation  of  the 
constitutional  condition  of  the  patient  with  a  view  of  ascertaining 
whether  he  is  endowed  with  sufficient  resistance  to  counteract  the 
ravages  of  the  disease. 

History  of  the  Patient. — This  is  to  be  minutely  inquired  into.  We 
find  out  the  condition  of  health  or  the  cause  of  death  of  the  patient's 
parents,  and  grandparents,  if  he  is  in  possession  of  the  facts,  or  capable 
of  giving  them  to  us  reliably,  which  unfortunately-  is  only  rarely  the 
case.  Of  particular  importance  is  whether  either  of  the  parents  was 
actively  tuberculous  when  the  patient  was  an  infant.  In  case  the 
parents  have  })ec()me  actively  tuberculous  when  the  ])a.tient  had 
already  passed  childhood,  his  chances  of  becoming  phthisical  are  not 
greater  than  of  those  who  do  not  ha\c  such  a  hereditary  taint .    In 


HISTORY  OF   THE  PATIENT  147 

fact,  there  appears  to  be  some  evidence  tending  to  show  that,  contrary 
to  the  general  opinion,  tuberculosis,  if  it  occurs  at  all  in  such  individ- 
uals, is  apt  to  run  a  milder  course  than  in  those  who  have  no  family 
history  of  tuberculosis  (see  page  112). 

We  should  not  be  influenced  by  the  age  of  the  patient.  No  age  is 
immune  to  the  disease,  but  each  age  period  appears  to  have  its  own 
form  of  the  disease:  In  infants  hematogenic  general  tuberculosis  is 
the  rule;  in  children  tuberculosis  of  the  glands,  especially  the  tracheo- 
bronchial group,  the  bones  and  joints;  in  adults  chronic  pulmonary 
tuberculosis;  in  persons  over  forty  fibroid  phthisis,  and  in  aged  indi- 
viduals a  very  chronic  form  with  a  symptomatology  peculiarly  its 
own,  etc. 

The  occupation  of  the  patient  has  great  influences  on  the  chances 
of  developing  active  phthisis,  as  was  already  shown  elsewhere,  and 
should  be  considered  when  taking  the  history  of  the  patient.  A 
history  of  an  injury  to  the  chest,  especially  if  followed  by  hemoptysis, 
is  important. 

Preexisting  diseases  are  to  be  ascertained  in  detail.  In  infants  and 
children  active  disease  is  apt  to  follow  in  the  wake  of  one  of  the  endemic 
contagious  diseases;  in  adults,  typhoid,  pleurisy,  pneumonia,  dia- 
betes, syphilis,  etc.,  are  of  etiological  moment.  A  history  of  scrofula 
during  childhood  has  very  little  bearing  upon  active  phthisis  in  the 
adult,  excepting  perhaps  that  if  the  disease  does  occur,  it  is  likely  to ' 
pursue  a  mild  and  exceedingly  chronic  course.  The  same  is  true  to  a 
certain  extent  of  previous  tuberculous  disease  of  the  bones  and  joints. 
One  has  to  consider  the  rarity  of  old  scars  on  the  neck  or  over  joints 
of  phthisical  patients;  or  of  phthisis  in  those  who  have  had  Pott's 
disease  during  childhood. 

In  women  the  menstrual  history  is  to  be  gone  into  and  special 
attention  paid  to  amenorrhea.  It  is  also  to  be  borne  in  mind  that 
active  symptoms  very  often  appear  immediately  after  childbirth. 

A  history  of  exposure  to  infection  should  not  be  overestimated  in 
adults,  as  has  been  advised  by  many  writers.  We  have  seen  that 
those  most  exposed  to  infection  with  tubercle  bacilli,  as  the  hospital 
stafl's — doctors,  nurses  and  orderlies — are  not  more  liable  to  become 
phthisical  than  those  in  other  walks  of  life  who  do  not  come  into 
intimate  contact  with  consumptives;  nor  do  the  unaffected  consorts 
of  tuberculous  patients  suflfer  from  this  disease  more  than  others. 
It  is  therefore  absurd  to  expect  that  working  with  a  tuberculous  fellow- 
workman  is  more  likely  to  transmit  the  disease  than  to  a  doctor, 
nurse  or  unaffected  consort.  In  my  own  practice  I  do  not  at  all  give 
exposure  to  infection  any  weight  in  the  diagnosis  of  active  phthisis 
in  adults.  It  is  different  with  children,  especially  with  infants.  Infants 
of  tuberculous  parentage,  or  who  have  otherwise  been  exposed  to 
infection,  are  very  likely  to  have  contracted  the  disease  in  an  active 
form.  With  children  over  three  we  should  ascertain  whether  the 
parent  has  become  actively  tuberculous  while  the  child  was  less  than 


148  SYMPTOMATOLOGY  OF  PHTHISIS 

one  year  old,  because  if  the  child  was  older  than  three  years  when 
the  parent  began  to  expectorate  bacilli,  the  chances  of  primary  massive 
infection  of  the  child  are  remote. 

It  is  a  curious  fact  that,  in  attempting  to  trace  the  source  of 
infection  in  children,  we  often  find  it  is  one  of  the  grandparents, 
suffering  from  senile  phthisis,  who  is  responsible,  though  he  or  she  is 
ignorant  of  the  true  nature  of  the  ailment,  having  been  told  that  it 
is  bronchitis,  emphysema,  asthma,  etc. 

History  of  the  Present  Illness. — Of  immense  importance  is  the 
history  of  the  mode  of  onset  of  the  present  ailment,  as  well  as  certain 
symptoms  from  which  the  patient  has  suffered  during  his  lifetime. 
Previous  attacks  of  "grippe,"  "colds,"  bronchitis,  etc.,  may  mean 
previous  attacks  of  abortive  phthisis  and  should  be  carefully  con- 
sidered. The  same  may  be  true  of  typhoid  fever,  pneumonia,  etc., 
which  may  have  been  attacks  of  acute  tuberculosis  which  have  sub- 
sided. Having  been  treated  for  months  for  neurasthenia,  gastritis, 
chlorosis,  or  even  malaria  is  not  uncommonly  ascertained  in  the 
history. 

We  should  inquire  into  the  symptoms  which  ushered  in  the  present 
ailment,  with  special  reference  to  cough,  expectoration,  lassitude, 
languor,  particularly  in  the  afternoon,  loss  of  weight,  hemoptysis, 
pleuritic  pains,  or  pleurisy  with  or  without  effusion,  etc.  Of  most 
importance  in  ascertaining  the  presence  or  absence  of  active  disease 
is  fever  with  its  concomitant  symptoms — chills,  backache,  anorexia, 
tachycardia,  etc.  Nightsweats  are  to  be  inquired  iuto  and  it  should 
be  ascertained  whether  they  occur  immediately  upon  going  to  bed, 
or  wake  the  patient  at  some  time  during  the  night.  The  appetite  of 
the  patient  is  to  be  ascertained,  and  whether  any  loss  in  this  direction 
has  been  concomitant  with  the  appearance  of  other  symptoms.  If 
the  patient  knows,  he  should  tell  the  fluctuations  in  his  weight  for 
the  past  several  years.  The  condition  of  the  bowels,  especially  the 
presence  of  diarrhea  is  to  be  ascertained. 

Of  course,  if  any  sputum  is  available  it  should  be  examined  micro- 
scopically for  tubercle  bacilli  and  chemically  for  albumin.  The  urine 
should  be  analyzed  for  the  presence  or  absence  of  albumin,  sugar,  and 
casts. 

After  all  these  data  have  been  ascertained  we  proceed  with  the 
physical  examination  of  the  patient,  and  this  includes  not  only  a  care- 
ful examination  of  the  chest  by  inspection,  palpation,  percussion  and 
auscultation,  but  also  all  other  parts  of  the  body  from  the  top  of  the 
head  to  the  toes.  We  may  thus  find  symptoms  and  signs  confirm- 
ing the  diagnosis  of  phthisis,  or  provmg  that  the  symptoms  of  which 
the  patient  complains  are  due  to  some  other  cause.  The  stigmata 
of  phthisis  are  often  scattered  all  over  the  body,  as  will  be  shown 
later  on. 

Above  all,  it  must  never  be  lost  sight  of  that  while  there  is  no  active 
phthisis  without  constitutional  symptoms,  there  is  no  single  symptom 


IMPORTANCE  OF  THE  SYMPTOMATOLOGY  OF  PHTHISIS    149 

or  sign  pathognomonic  of  the  disease,  excepting  the  expectoration  of 
sputum  containing  tubercle  bacilh,  and  even  this  is  occasionally  apt 
to  mislead.  It  is  only  the  combination  of  various  symptoms  and 
signs  which  clinches  the  diagnosis,  especially  in  obscure  cases  with 
negative  sputum.  This  fact  by  no  means  interferes  with  the  early 
recognition  of  active  phthisis,  and  mistakes  are  more  often  due  to 
carelessness  in  observation  than  to  any  other  factor. 

Importance  of  the  Symptomatology  of  Phthisis. — In  the  succeeding 
chapters  the  physical  diagnosis  of  phthisis  in  its  various  forms  will 
be  given  its  proper  place,  because  only  with  the  aid  of  inspection,  per- 
cussion, and  auscultation  can  we  localize  the  lesion  and  gain  impor- 
tant hints  as  to  prognosis  and  the  treatment  indicated.  The  symp- 
tomatology of  the  disease,  which  has  been  given  a  subordinate  place 
in  some  recent  treatises  on  the  subject,  will  be  discussed  in  detail. 
The  reasons  a,re  obvious;  The  general  symptomatology  of  active 
phthisis  can  be  ascertained  by  every  practising  physician  and  its 
bearings  on  the  presence  or  absence  of  active  phthisis,  especially  in 
doubtful  cases,  are  of  more  significance  than  indefinite  physical  signs. 
There  may  be  active  phthisis  without  physical  signs  revealing  them- 
selves even  to  the  best-trained  specialist,  and  many  signs  of  apical 
involvement  are  found  in  healthy  persons.  But  there  is  no  active 
phthisis  without  constitutional  symptoms.  This  is  an  axiom  which 
cannot  be  repeated  too  often.  The  symptomatology  of  phthisis,  when 
properly  studied  and  interpreted,  gives  information  as  to  the  onset 
of  the  disease,  its  activity,  tendency,  and  ultimate  outlook.  It  can  -be 
ascertained  by  any  medical  man.  Inasmuch  as  it  often  precedes  the 
appearance  of  definite  physical  signs,  or  the  signs  elicited  with  the  aid 
of  skiagraphy,  the  symptomatology  of  the  disease  is  to  be  ascertained 
first. 

We  shall  therefore  begin  with  a  discussion  of  the  most  prominent 
and  more  or  less  constant  symptoms  of  active  phthisis — cough, 
expectoration,  fever,  nightsweats,  hemoptysis,  anorexia,  emaciation, 
tachycardia,  etc.  Each  of  these  symptoms  will  be  discussed  from  the 
standpoint  of  diagnosis,  differential  diagnosis,  and  prognosis.  It  is 
only  by  a  proper  appreciation  of  these  symptoms  that  a  diagnosis  of 
active  phthisis  can  be  made  at  any  stage  of  the  disease,  but  especially 
in  the  so-called  incipient  stage;  while  a  prognosis  based  only  on 
findings  during  a  physical  examination  and  skiagraphy  is  bound  to 
prove  ruinous  to  any  practitioner. 


CHAPTER  VIII. 
COUGH  AND  EXPECTORATION. 

COUGH. 

Frequency  of  Cough. — While  cough  is  the  symptom  which  first 
attracts  the  attention  of  the  average  patient  to  his  troubles,  there 
has  been  a  question  whether  there  are  cases  of  phthisis  without 
cough.  Pidoux  stated  that  cough  is  the  first  and  last  symptom  of 
phthisis;  when  it  is  absent,  its  negative  significance  is  almost  abso- 
lute. According  to  many  writers,  a  patient  who  does  not  cough  is 
not  tuberculous,  while  there  are  others  who  consider  it  the  most 
constant  of  symptoms  of  early  phthisis.  However,  Louis,  Wilson 
Fox,  Moeller,  and  others  speak  of  patients  who  passed  through  the 
disease  without  ever  coughing. 

This  disagreement  is  due  to  various  causes.  The  statement  made 
by  many  phthisical  patients  to  the  effect  that  they  do  not  cough  is 
to  be  taken  with  considerable  qualification.  ]\Iild  cough,  clearing 
the  throat  in  the  morning,  or  hawking,  which  causes  but  little  anoy- 
ance to  individuals  who  are  not  given  to  introspection,  may  be  over- 
looked. Even  in  the  advanced  stages,  when  the  patient  brings  up 
considerable  sputum,  there  may  be  no  cough — the  sputum  is  carried 
by  the  cilia  of  the  bronchial  mucous  membranes  and  when  it  reaches 
the  vocal  cords  it  is  easily  removed  without  effort,  or  swallowed.  In 
the  latter  case  the  patient  may  not  even  expectorate.  I  have  seen 
this  to  be  the  case  with  many  patients,  especially  females.  For  this 
reason,  it  is  often  ascertained  by  close  questioning  that  there  is  little, 
mild  cough,  "just  like  everybody  else  coughs."  I  have,  however, 
seen  many  patients  in  whom  physical  exploration  of  the  chest  was 
negative  for  quite  some  time,  but  the  continuous  cough,  producti^•e 
or  unproductive,  w^as  the  only  symptom  which  urged  them  to  seek 
a  diagnosis,  and  excited  a  careful  study  of  the  case  by  the  physician. 

Another  class  of  patients  who  do  not  cough  despite  active  tuber- 
culosis, are  aged  persons,  of  whom  details  will  be  given  later  on.  The 
same  is  true  of  some  cases  of  phthisis  with  ca\ities — mouthfuls  of 
sputum  may  be  brought  up  without  any  efforts  or  cough,  as  in  bron- 
chiectasis. 

Cough  in  the  Early  Stage  of  Phthisis. — A  considerable  number  of 
patients  give  a  history  of  repeated  "colds"  caught  during  several 
preceding  winters  or  autumns;  or  of  attacks  of  "grii)pe"  which  made 
them  cough  more  or  less  violently,  but  they  subsided  under  ordinary 
treatment.     Owing  to  some  neglect,  the  last  attack  has  been  per- 


COUGH  151 

sistent,  the  cough  aggravated  and  could  not  be  reheved  by  the  remedy 
which  helped  them  formerly.  The  cough  in  these  cases  is  apt  to  be 
rather  mild,  consisting  mainly  in  clearing  the  throat  in  the  morning 
and  may  not  at  all  be  productive  of  sputum;  or  small  lumps  of  clear, 
vitreous  secretion  from  the  nasopharynx  may  be  brought  out.  Rarely 
mucopurulent  material  is  eliminated,  but  it  is  usually  devoid  of 
tubercle  bacilli  at  this  stage. 

These  repeated  attacks  of  grippe  or  bronchitis,  which  subside  during 
the  summer  to  return  during  the  autumn  and  winter  and  are  easily 
managed  by  ordinary  sedatives,  often  give  the  patient  a  false  sense  of 
security  and  when  told  that  the  ©ough  is  of  tuberculous  origin  he  is 
loath  to  agree  to  it. 

This  mild  cough  is  to  be  differentiated  from  hysterical  cough  which 
is  very  frequent  at  present  when  phthisiophobia  is  rampant.  In  fact 
in  many  homes  with  tuberculous  patients,  most  of  the  healthy  mem- 
bers of  the  family  cough,  believing  they  are  affected  with  the  disease. 
Perhaps  the  best  sign  is  that  hysterical  cough  does  not  occur  at  night, 
when  the  patient  is  asleep,  or  during  the  day,  when  he  is  absorbed 
in  some  matter  which  interests  him,  I  have  seen  patients  who 
coughed  persistently,  cease  coughing  during  the  time  they  were  engaged 
in  an  interesting  conversation.  The  cough  in  incipient  phthisis  is 
annoying  at  bedtime,  disappearing  during  the  first  hours  of  sleep, 
and  reappearing  during  the  early  morning  hours,  often  waking  the 
patient,  while  after  rising  it  may  be  intense  till  the  chest  is  cleared. 
During  the  day  it  may  be  scarce  or  absent  and  provoked  only  by 
emotional  disturbance,  undue  exertion,  chilling  the  body,  a  dusty  or 
smoky  atmosphere,  etc. 

Paroxysmal  Cough. — In  many  patients  at  the  onset  of  the  dis- 
ease, or  during  its  later  stages,  the  cough  is  violent  and  paroxysmal; 
occurring  in  fits.  When  unproductive  it  may  be  difficult  to  bear 
because  it  often  increases  in  intensity  during  the  evening  and  keeps 
the  patient  awake  during  the  night,  causing  pain  in  the  chest,  insom- 
nia, and  exhaustion.  In  others  the  fits  keep  up  for  quite  some  time 
till  a  small  piece  of  viscid  mucus  is  expelled.  The  first  thing  these 
patients  ask  for  is  a  remedy  which  will  loosen  the  sputum.  During 
such  spells  vomiting  may  occur,  or  even  involuntary  evacuation  of 
urine,  especially  in  women  with  lacerated  genitals.  The  paroxysmal 
explosions  of  cough  are  a  frequent  cause  of  hernia  in  men,  especially 
in  those  suffering  from  fibroid  phthisis. 

Paroxysmal  cough  in  phthisis  is  said  to  be  due  to  ulceration  of  the 
trachea  or  its  bifurcation.  But  it  is  also  met  with  in  cases  of  tracheo- 
bronchial adenopathy.  Its  occurrence  during  periodical  evacuation 
of  pulmonary  cavities  will  be  discussed  later  on. 

Patients  suffering  from  fibroid  phthisis,  and  those  who  have  tuber- 
culosis evolving  in  emphysematous  lungs  suffer  at  times  from  severe 
paroxysms  of  cough.  In  these  the  cyanosis  and  congestion  of  the 
veins  of  the  neck  and  face  are  strong  features  during  a  paroxysm,  and 


152  COUGH  AND  EXPECTORATION 

the  suffering  may  be  extreme.  The  violence  of  the  cough  is  usually 
far  out  of  proportion  to  the  amount  of  sputum  brought  up.  After 
the  expulsion  of  a  small  lump  of  transparent  mucus  they  feel  relieved 
but  exhausted,  to  be  annoyed  again  at  longer  or  shorter  intervals. 
Nocturnal  attacks  are  not  uncommon. 

I  have  observed  similar  paroxysms  of  violent  cough  in  many  cases 
of  galloping  consumption  in  which  the  lesions  were  not  localized;  also 
in  miliary  tuberculosis  with  tubercles  widely  disseminated  all  over 
the  lungs  and  signs  of  pulmonary  emphysema  were  elicited  on  physical 
exploration  of  the  chest.  The  violence  of  the  cough  may  be  responsible 
for  the  extensive  dissemination  of  the  tubercles  by  metastasis.  But 
in  many  cases  under  my  care  the  lesion  finally  localized  itself  and  the 
disease  pursued  the  usual  course  of  chronic  phthisis,  the  paroxysmal 
cough  disappearing,  leaving  the  common  cough  encountered  in  the 
average  case  of  the  disease. 

The  Emetic  Cough. — First  described  by  Richard  Morton  at  the 
end  of  the  seventeenth  century,  the  cough  ending  in  vomiting  is  quite 
frequently  met  with  in  the  early  stage  of  phthisis  in  various  degrees 
of  intensity.  Some  French  authors,  notably  Paillard,^  state  that  the 
sig7ie  de  Morton,  or  the  toux  emetisante  as  they  call  it,  is  met  with  to 
the  extent  of  50  to  60  per  cent,  of  all  cases  of  phthisis.  This  has  not 
been  the  case  with  the  patients  under  my  care.  To  be  sure,  vomiting 
may  be  seen  in  more  than  one-half  the  cases  of  tuberculosis  at  some 
period  of  the  course  of  the  disease,  but  not  all  vomiting  is  the  result 
of  the  true  emetic  cough,  as  we  shall  soon  show. 

It  has  been  stated  that  the  cough  of  incipient  phthisis  often  pro- 
duces no  expectoration,  but  vomiting.  There  are  tuberculous  patients 
who  cough  as  soon  as  they  eat,  says  Michel  Peter,^  there  are  others 
who  cough  because  they  eat;  there  are  finally  others  who,  having 
eaten,  cough,  vomit  and  suffer  from  cardiac  palpitation.  This  cough 
is  so  characteristic  that  when  whooping-cough  is  ruled  out,  I  place 
great  reliance  on  it  in  doubtful  cases  and  it  has  often  helped  me  in 
making  a  positive  diagnosis  sooner  than  I  could  have  made  it  without 
this  symptom.  But  to  appreciate  its  diagnostic  significance  it  must 
not  be  confounded  with  vomiting  of  other  origin  which  may  occur 
in  phthisis.    It  usually  occurs  in  the  following  manner: 

The  patient  has  had  his  lunch  or  dinner  with  a  variable  appetite  and 
feels  rather  satisfied,  having  no  sensation  of  gastric  disturbance,  except- 
ing perhaps  some  feeling  of  epigastric  distention  or  mild  dyspnea.  But 
after  the  lapse  of  some  time,  from  five  minutes  to  an  hour — an  average 
of  about  twenty  minutes — the  patient,  either  without  any  warning  at 
all,  or  feeling  some  irritation  at  the  back  of  the  throat,  is  seized  with  a 
paroxysm  of  cough  which  nearly  chokes  him ;  he  feels  as  if  he  is  unable 
to  expel  a  piece  of  tenacious  mucus  which  sticks  in  his  throat.  Finally 
he  vomits  out,  in  part  or  completely,  the  gastric  contents  which  are 

'  La  toux  emetisante  des  tuberouloux,  Paris,   1911. 
-  Lcpons  de  Clinique  ni6dicale,  Paris,  1879,  ii,  318. 


COUGH  153 

in  a  variable  state  of  digestion,  according  to  the  time  they  remained  in 
the  stomacli.  There  is  no  sensation  of  nausea  before  the  paroxysm,  but 
the  vomiting  comes  on  suddenly  during  the  coughing  spell;  a  fact 
which  differentiates  this  form  of  vomiting  from  other  forms.  When 
occurring  for  the  first  time  the  patient  is  alarmed,  and  is  inclined  to 
attribute  it  to  some  dietetic  indiscretion,  but  if  it  occurs  repeatedly 
he  is  compelled  to  seek  another  cause.  As  soon  as  the  vomiting  ceases 
the  patient  usually  feels  greatly  relieved,  the  sensation  of  gastric 
distention  and  the  dyspnea  disappear  and  at  times  he  may  express 
a  desire  to  eat  again.  After  a  time  the  patient  learns  prudence  from 
experience — he  knows  that  a  heavy  meal  may  bring  about  a  fit  of 
cough  followed  by  vomiting. 

During  the  course  of  phthisis  there  occur  also  other  varieties  of 
vomiting  which  cannot  be  classified  under  the  heading  of  the  emetic 
cough.  Patients  who  have  been  sufferers  from  chronic  gastritis, 
dilatation  of  the  stomach,  and  chronic  alcoholism  often  vomit;  at 
times  vomiting  is  provoked  by  cough.  In  the  advanced  stages  of  the 
disease  vomiting,  preceded  by  cough  or  not,  may  occur  and  in  some 
patients  it  may  be  so  pronounced  as  to  preclude  feeding.  But  these 
forms  of  the  vomiting  are  not  the  true  emetic  cough.  These  patients 
usually  suffer  from  symptoms  of  indigestion,  furred  tongue,  foul 
breath,  constipation,  diarrhea,  headache,  etc.  Examination  usually 
reveals  a  dilated  stomach,  amyloid  or  fatty  degeneration  of  the 
liver,  symptoms  of  tuberculous  peritonitis,  etc.  Moreover,  while 
the  vomiting  may  occur  after  coughing,  yet  it  is  not  invariably  pre- 
ceded by  paroxysmal  cough,  occurs  irregularly,  not  always  after 
the  ingestion  of  food,  and  there  is  no  relief  immediately  after  the 
vomiting.  In  alcoholics  the  vomiting  is  more  apt  to  occur  in  the 
morning,  and  this  is  also  the  rule  with  those  in  whom  the  cough  is 
due  to  chronic  pharyngitis.  In  both  these  conditions  nausea,  retching, 
etc.,  are  common,  while  in  the  true  emetic  cough  they  are  absent. 
The  emetic  cough  often  occurs  in  the  early  stages  of  phthisis,  in 
patients  in  whom  the  gastric  functions  are  in  good  condition,  is 
always  preceded  by  spells  of  cough,  always  occurs  at  a  certain  time 
after  the  ingestion  of  food,  is  not  preceded  nor  followed  by  sensations  of 
nausea,  giddiness,  faintness,  and  retching.  The  reverse,  vomiting  and 
then  coughing,  is  never  observed. 

This  form  of  vomiting,  or  the  emetic  cough,  is  observed  in  practice 
in  but  a  few  diseases,  namely,  phthisis,  whooping-cough,  and  in  certain 
forms  of  pharyngitis.  So  that  when  whooping-cough  is  excluded  in  a 
patient  with  an  emetic  cough,  and  the  pharynx  is  found  to  be  in  good 
condition,  phthisis  is  at  once  to  be  thought  of.  If  it  persists,  a  diag- 
nosis of  tuberculosis  may  be  made  even  in  the  absence  of  definite 
physical  signs  of  the  disease. 

Some  authors  have  been  inclined  to  look  at  the  emetic  cough  as 
a  mechanical  accident,  comparable  with  that  observed  in  whooping- 
cough.      But  it  appears  that   this    does   not    entirely  explain    this 


154  COUGH  AND  EXPECTORATION 

phenomenon.  If  the  compression  of  the  abdominal  muscles  and 
stomach  were  the  sole  cause,  we  should  expect  that  during  violent 
and  prolonged  asthmatic  paroxj^sms,  vomiting  to  occur.  But  I 
have  never  seen  a  patient  suffering  from  asthma  vomit  after  an 
attack  of  cough  and  dyspnea  and  be  relieved  immediately  after  the 
gastric  contents  have  thus  been  expelled. 

As  has  been  pointed  out  by  Michel  Peter,  W.  Soltau  Fenwick,^ 
Paillard,  and  others,  the  emetic  cough  appears  to  be  purely  a  reflex 
phenomenon,  due  to  irritation  by  the  ingested  food  of  the  gastric 
ends  of  the  vagus  and  an  abnormal  excitability  of  the  respiratory 
centre.  Hence,  the  slightest  irritation  of  the  gastric  mucous  mem- 
brane by  particles  of  food  is  sufficient  to  produce  a  violent  attack  of 
reflex  cough  which  can  bring  about  vomiting  in  a  mechanical  manner. 

Cough  during  the  Advanced  Stages  of  Phthisis. — With  the  advance 
of  the  disease  the  cough  becomes  more  and  more  abundant,  more 
productive,  but  easier  and  less  exhausting.  After  the  formation  of 
cavities,  there  is  usually  observed  a  diminution  in  the  frequency  of 
the  cough,  sleep  is  hardly  disturbed  during  the  night  when  the  reflexes 
are  in  abeyance  and  the  secretions  accumulate  in  the  cavity.  But 
in  the  morning  when  compelled  to  empty  the  cavities  of  the  secre- 
tions there  are  fits  of  coughing  lasting  several  minutes,  perhaps  an 
hour,  and  the  patient  feels  relieved. 

These  patients,  like  those  suffering  from  bronchiectasis,  suffer 
from  cough  periodically  when  the  excavations  have  been  filled  and  need 
emptying.  It  may  be  influenced  by  posture — as  soon  as  they  change 
their  position,  the  secretions  overflow  the  bronchial  tubes  and  must 
be  brought  out  by  cough  which  does  not  cease  until  all  has  been 
discharged.  Then  there  is  relief  for  a  variable  time  until  the  cavity 
is  again  filled.  The  patients  usually  learn  from  experience  on  which 
side  to  sleep  if  they  want  to  have  peace.  It  is  not  always  on  the 
healthy  side  on  which  they  can  lie  with  more  or  less  comfort,  because, 
like  in  bronchiectasis,  it  depends  on  the  direction  of  the  bronchus  or 
sinus  which  empties  the  cavity.  Patients  with  pleural  effusions  also 
cough  when  changing  their  positions,  but  in  their  case  the  cough  is 
usually  dry  and  is  not  instrumental  in  bringing  up  abundant  sputum. 
For  obvious  reasons,  patients  cough  more  when  lying  down  than  when 
in  the  upright  position. 

In  some  cases  the  cough  at  this  stage  is  very  severe  and  almost 
incessant,  painful,  and  preventing  rest  day  and  night ;  actually  exhaust- 
ing. It  is  noteworthy  that  the  severity  of  the  cough  does  not  alto- 
gether depend  on  the  extent  of  the  lesion  in  the  lung,  nor  on  the  size 
and  number  of  the  cavities.  Some  will  cough  very  little,  although  the 
lungs  are  extensively  involved,  while  others,  with  limited  infiltrations 
or  excavations,  cough  severely. 

The  cough  of  tuberculous  patients  is  often  greatly  influenced  by 

1  The  Dyspepsia  of  Phthisis,  London,  1894,  p.  118. 


COUGH  155 

various  factors,  of  which  the  age  and  the  emotional  state  are  most 
important.  Young  adults  cough,  as  a  rule,  more  than  old  consump- 
tives. In  fact,  a  large  proportion  of  old  people  suffering  from  phthisis 
hardly  cough;  they  bring  up  large  quantities  of  sputum  without 
an}^  effort.  They  are  the  patients  who  supply  the  material  for  those 
who  describe  cases  which  have  been  sick  with  the  disease  for  many 
years  and  never  coughed.  The  psychic  state  of  the  patient  also  has 
a  great  influence.  The  nervous,  irritable,  and  hysterical  cough  more 
than  the  indolent  and  phlegmatic.  The  former  class  is  also  more 
apt  to  suffer  from  the  emetic  form  of  cough. 

Diagnostic  and  Prognostic  Significance. — On  the  whole,  cough 
serves  a  very  good  purpose  by  drawing  the  attention  of  many  patients 
to  the  condition  of  their  lungs.  A  person  who  never  coughed,  but 
"caught  cold"  for  the  first  time  after  his  twentieth  year,  and  as  a 
result  keeps  on  coughing  for  more  than  a  month,  is  to  be  strongly 
suspected  of  being  tuberculous,  even  if  there  are  no  definite  physical 
signs  of  a  pulmonary  lesion.  The  suspicion  is  fortified  by  a  history 
of  the  absence  of  acute  coryza  during  the  first  few  days  of  illness 
because  simple  bronchitis  and  "grippe"  are  almost  always  preceded 
or  accompanied  by  nasopharyngeal  catarrh. 

From  the  prognostic  viewpoint  cough  is  important  because  we 
meet  cases  with  small  pulmonary  foci  without  much  fever,  anorexia, 
emaciation,  etc.,  who  would  undoubtedly  do  well  but  for  a  cough 
which  is  difficult  to  control.  If  violent,  paroxysmal,  and  continuing 
for  some  time,  the  cough  may  be  instrumental  in  extending  the  lesion, 
exhausting  the  patient  and  thus  aggravating  the  outlook.  It  also 
irritates  the  larynx,  trachea,  bronchi,  and  pulmonary  parenchyma, 
and  predisposes  these  organs  to  infection  by  metastasis  of  the  bacilli. 
Violent  fits  of  cough  may  also  be  responsible  for  spontaneous  pneumo- 
thorax in  cases  in  which  the  lesion  is  located  superficially  or  sub- 
pleurally.  Kuthy  and  Wolff-Eisner^  say  that  the  most  unfavorable 
prognosis  is  to  be  given  in  cases  in  which  the  patient  coughs  during 
both  day  and  night;  relatively  more  favorable  is  the  outlook  when  he 
coughs  during  the  day  exclusively;  more  favorable  when  he  coughs 
only  mornings  and  evenings;  and  most  favorable  when  he  coughs 
exclusively   in  the   morning. 

Within  certain  limits  cough  also  gives  other  prognostic  hints.  With 
each  improvement  in  the  local  or  general  condition  the  cough  also 
improves  or  disappears,  and  with  every  recrudescence  of  cough  we 
may  find  an  extension  of  the  process  in  the  lungs,  or  some  complication 
in  the  bronchi  or  nasopharynx.  Occasionally  we  may  note  that  the 
sudden  disappearance  of  cough  is  a  signal  of  some  grave  complication 
of  phthisis,  especially  meningitis  or  peritonitis.  The  same  is  at  times 
seen  in  cases  of  severe  ulcerations  of  the  larynx,  causing  dysphagia, 
etc.      The  cough  may  be  ameliorated,  but  the  lesion  in  the  lungs 

'  Die  Prognosenstellung  bei  der  Lungentuberkulose,  Berlin,  1914,  p.  219. 


156  COUGH  AND  EXPECTORATION 

continues  or  extends  and,  combined  with  the  exhaustion  due  to  lack 
of  nourishment,  the  end  is  not  very  far. 

Hoarseness. — Changes  in  the  timbre  of  the  voice  may  appear  quite 
early  in  the  disease  without  any  tuberculous  involvement  of  the 
larynx.  The  least  provocation,  such  as  changes  in  the  weather,  or 
prolonged  speaking,  may  produce  dysphonia,  or  a  muffled  voice 
without  any  pain  which,  with  the  dyspnea  preventing  speaking 
continuously  long  sentences,  may  be  quite  troublesome. 

In  many  cases  the  hoarseness  is  due  to  simple  catarrh  caused  by 
chemical  irritation  of  the  larynx  by  the  secretions  while  they  are  being 
eliminated  from  the  lungs.  In  others,  pressure  of  a  tuberculous 
gland,  lying  between  the  trachea  and  the  esophagus,  on  the  recurrent 
laryngeal  nerve  causing  adductor  paralysis,  is  the  cause.  Often  the 
hoarseness  is  due  to  tenacious  secretions  sticking  to  the  vocal  cords, 
and  after  coughing  strongly  they  are  dislodged  and  the  voice  is  again 
normal.  Congestion  of  the  larynx  caused  by  violent  fits  of  coughing 
may  be  the  reason  for  hoarseness. 

It  is  thus  evident  that  not  all  cases  of  hoarseness,  or  even  dysphagia, 
are  due  to  tuberculous  ulcerations  of  the  larynx.  In  fact,  no  diagnosis 
of  the  latter  condition  should  be  made  without  a  careful  and  pains- 
taking inspection  of  the  larynx  with  a  mirror. 


EXPECTORATION. 

Careful  inquiry  reveals  in  most  cases  that  the  cough  preceded  expec- 
toration by  several  weeks  or  even  months,  and  we  must  not  unequivo- 
cally conclude  that  because  the  cough  is  unproductive  we  are  not  deal- 
ing with  phthisis.  Children  before  the  sixth  year  never  bring  up  any 
sputum  at  all,  because  they  unconsciously  swallow  it,  and  most  women 
do  the  same.  I  have  met  with  cases  in  which  urging  women  to  expec- 
torate was  of  no  avail.  Many  men  are  not  much  better  in  this  regard 
and  for  reasons  of  false  delicacy  they  swallow  the  sputum,  especially 
during  the  early  stages  of  the  disease.  In  the  advanced  stage  we  may 
meet  with  the  same  condition  when  the  patient  is  exliausted  and 
hardly  has  any  strength  to  rise  or  turn  around  in  bed  and  expectorate 
into  the  sputum  cup. 

With  the  advance  of  the  disease  the  quantity  of  sputum  eliminated 
increases,  but  I  have  met  with  cases  showing  extensive  infiltrations  of 
more  than  one  lobe,  without  any  substantial  expectoration,  and  in 
some  of  these  I  have  been  convinced  that  they  had  not  swallowed  the 
sputum.  It  was  merely  an  indication  that  the  tubercles  had  not 
broken  through  a  bronchus. 

Macroscopic  Appearance  of  the  Sputum. — There  is  nothing  typical 
about  the  naked-eye  appearance  of  the  sputum  in  early  phthisis, 
although  ancient  clinicians  gave  detailed  descriptions  of  topical 
tuberculous  sputum.     Perhaps  the  fact  that  they  knew  very  little 


EXPECTORATION  157 

about  early  phthisis  will  account  for  their  confidence  in  the  gross 
appearance  of  the  sputum  in  this  disease. 

In  the  early  stages  we  find  that  the  sputum  is  scanty;  at  times  it 
is  altogether  absent.  Kuthy  found  that  in  49  per  cent,  of  cases  in  the 
first  stage,  15.4  per  cent,  of  the  second  stage,  and  12  per  cent,  of  the 
third  stage,  sputum  was  altogether  absent.  What  is  usually  brought 
up  in  the  early  stages  is  viscid  mucus,  occasionally  with  some  dark 
points;  it  is  often  frothy  and  floats  on  water,  hardly  differing  from 
the  expectoration  in  bronchitis. 

With  the  advance  of  the  disease  the  sputum  becomes  thicker, 
although  it  remains  glassy  or  transparent  for  some  time,  but  yellow 
streaks  are  to  be  seen  indicating  that  it  is  assuming  a  purulent  char- 
acter. Later  its  appearance  and  consistency  change:  It  becomes 
mucopurulent  and  finally  purulent,  indicating  that  softening  of  lung 
tissue  has  taken  place  and  the  necrotic  parts  are  being  eliminated. 
The  purulent  character  of  the  expectoration  is  judged  by  the 
yellow,  yellowish-green,  or  green  color  it  assumes.  Pure  purulent 
sputum  without  froth  is  mostly  seen  in  cases  in  which  an  abscess  or 
pyopneumothorax  has  broken  through  a  bronchus. 

In  the  far-advanced  stage  of  the  disease  the  sputum  is  usually  dark 
gray  or  greenish  in  color,  made  up  of  roundish  balls  which  float  around 
like  islands  in  the  fluid  mucus  or  saliva  or,  when  thicker  in  consistency, 
sink  down  to  the  bottom  of  the  receptacle  where  it  settles  in  disk  or 
coin-shaped  masses  which  keep  apart  and  do  not  coalesce.  This 
is  the  nummular  sputum  of  old  physicians  which  had  erroneously 
been  considered  pathognomonic  of  phthisical  excavations.  At  times 
whitish,  cheesy  masses,  derived  from  broken-dowli  tubercles,  are 
seen  scattered  within  this  sputum. 

This  sputum  is  usually  odorless,  but  at  times  it  acquires  a  very 
disagreeable,  sweetish,  but  nauseating  odor,  especially  when  retained 
within  the  chest  by  narcotic  drugs,  or  weakness  of  the  patient.  Fetid 
sputum  of  this  character  is  exceedingly  rare  in  phthisis.  Whenever 
it  is  met  with  we  should  look  for  complicating  pulmonary  gangrene, 
which  occurs  at  times.  Very  rarely  it  is  due  to  fetid  bronchitis.  It  is 
usually  salty  in  the  early  stages  but  later  it  often  acquires  a  sweetish, 
sickening  taste. 

Very  often  this  sputum,  derived  from  tuberculous  cavities,  when 
allowed  to  stand  in  a  vessel  for  some  hours  separates  into  three  layers 
— an  upper  frothy  layer;  a  middle  thin  serous  layer;  and  a  lower 
layer  consisting  of  thick  plugs  of  pus.  This  is  characteristic  of  exca- 
vation but  not  of  necessarily  tuberculous  origin.  Bronchiectasis,  and 
also  chronic  bronchitis  with  copious  expectoration  may  also  be  pro- 
ductive of  sputum  which  separates  on  standing.  However,  in  the 
former  the  lines  of  demarcation  between  the  layers  are  not  as  distinct, 
but  one  passes  into  the  other  by  slow  gradations. 

There  are  cases  of  advanced  chronic  phthisis  with  scanty,  or  even 
without  any  expectoration,  especially  those  of  the  types  of  fibroid 


158  COUGH  AND  EXPECTORATION 

phthisis  or  with  emphysema,  although  they  have  periods  in  which 
the  expectoration  is  quite  profuse.  The  expectoration  decreases  in 
quantity  when  the  cavities  "dry  up"  during  the  process  of  heahng,  and 
in  other  cases  when  the  concomitant  bronchitis  disappears.  With 
but  few  exceptions,  scanty  expectoration  speaks  for  a  favorable  out- 
look, provided  the  cough  is  also  absent  or  mild.  On  the  other  hand, 
copious  expectoration  per  se  is  not  always  an  unfavorable  sign.  It  is 
an  indication  of  excavation,  bronchitis  or  bronchiectasis  which  are 
not  infrequent  in  phthisis.  In  the  latter  cases  the  sputum  may  show 
a  tendency  to  collect  and  be  expelled  at  intervals  in  very  large  quanti- 
ties— mouthfuls — without  any  effort,  and  may  also  be  influenced  by 
posture.  Of  course,  in  pyopneumothorax  breaking  through  the  lung, 
profuse  expectoration  of  purulent  material  is  seen. 

During  hemoptysis  the  material  expectorated  is  sanguineus  in  var- 
ious degrees,  corresponding  to  the  severity  of  the  bleeding,  and  for  a 
few  days  after  the  cessation  of  the  active  hemorrhage  the  sputum 
contains  dark  clots  derived  from  the  blood  that  has  coagulated  in  the 
bronchi  and  is  being  slowly  eliminated.  The  sputum  may  have  a 
reddish  or  chocolate  tinge  without  distinct  hemorrhage,  and  even 
rust}^  sputum  characteristic  of  pneumonia  is  at  times  encountered  in 
phthisis.  Inasmuch  as  this  is,  as  a  rule,  seen  during  an  acute  exacerba- 
tion of  fever,  etc.,  I  am  at  times  inclined  to  account  for  it  by  intercur- 
rent pneumonia.  In  some  advanced  cases  I  have  seen  at  the  terminal 
stage  thin,  watery  sputum,  dark  brown  in  color,  with  numerous  air 
bubbles — prune-juice  sputum — which  is  an  indication  of  pulmonary 
edema.  Green  sputum  is  at  times  met  with,  and  is  usually  ascribed  to, 
the  implantation  of  the  Bacillus  pyocyaneous.  In  cases  in  which  a 
pyopneumothorax  communicates  with  a  bronchus,  as  well  as  when 
an  empyema  breaks  through  a  bronchus,  the  sputum  may  be  distinctly 
purulent,  and  I  have  seen  cases  in  which  the  empyema  was  thus 
cured,  though  the  tuberculous  process  went  on  its  course. 

EXAMINATION  OF  THE  SPUTUM. 

Collection  of  Specimen. — In  cases  of  suspected  phthisis  the  sputum 
gives  important  information  which  is  often  of  more  value  than  all 
other  diagnostic  methods  for  this  disease.  This  is  especially  true  of 
the  microscopic  examination,  and  to  a  certain  extent  of  the  chemical 
examination. 

It  is  important,  especially  in  cases  with  scanty  expectoration,  that 
the  specimen  of  sputum  for  examination  should  be  properly  collected. 
The  patient  must  be  warned  that  what  we  want  is  material  that  has 
been  coughed  up  from  beneath  the  glottis,  and  not  what  has  been 
hawked  out  from  the  nasopharynx,  or  saliva.  A  clean,  wide-mouthed 
bottle  is  the  best  receptacle,  and  it  should  bo  tightl\-  corked.  The  one 
used  by  the  Health  Department  in  Xew  York  City  is  excellent.  In 
cases    with    scanty   expectoration,    a    twenty-foui'-lionr    specimen    is 


EXAMINATION  OF  THE  SPUTUM  159 

desirable,  but  with  others  the  quantity  coughed  up  during  the  morning 
on  rising  is  sufficient.  Fresh  sputum  is  best,  but  putrefaction  does 
not  interfere  with  the  appearance  of  the  bacilh  under  the  microscope. 

Microscopic  Examination.— In  incipient  cases  tubercle  bacilli  are 
more  often  absent  than  present  in  the  sputum,  and  it  is  only  when 
softening  of  tubercles  has  taken  place  and  the  diseased  focus  opens  into 
a  bronchiole  that  they  can  be  found.  In  general,  it  may  be  stated 
that  severe  cases  show  large  numbers  of  bacilli,  but  there  are  many 
exceptions.  In  fact,  in  acute  pneumonic  phthisis  bacilli  are  often 
lacking.  The  absence  of  bacilli  is  therefore  not  conclusive  proof  of 
the  non-tuberculous  character  of  a  case,  because  we  meet  with  un- 
doubted cases  of  tuberculosis,  proved  by  subsequent  autopsy  findings, 
in  which  no  bacilli  were  discovered  throughout  the  course  of  the 
disease.  In  general,  it  may,  however,  be  stated  that  these  "closed" 
cases  of  tuberculosis  run  a  more  favorable  course.  On  the  other 
hand,  in  acute  miliary  tuberculosis,  tubercle  bacilli  are  exceedingly 
rare. 

In  early  phthisis  in  which  it  is  difficult  to  obtain  sufficient  sputum 
for  examination,  the  administration  of  iodides,  5  grains  three  times 
a  day  for  a  couple  of  days,  may  increase  the  amount  of  expectoration. 
We  may  in  some  cases  also  administer  an  opiate  in  the  evening  with  a 
view  of  retaining  the  sputum  during  the  night,  so  that  it  may  be 
brought  up  in  the  morning  on  rising.  In  children,  swabbing  the 
throat  with  some  gauze,  as  suggested  by  Holt,  may  yield  a  specimen 
for  examination. 

Technic. — The  examination  is  best  and  most  rapidly  accomplished 
by  the  Ziehl-Neelsen,  the  Gabbet,  or  the  Hermann  methods,  which 
have  survived  numerous  modifications  introduced  during  recent  years. 

With  a  platinum-wire  loop  a  cheesy  or  mucopurulent  particle  is 
picked  out  and  spread  over  a  perfectly  clean  cover-glass  in  a  thin, 
uniform  layer.  It  is  even  better  that  a  small  amount  of  sputum 
should  be  spread  between  two  cover-glasses  which  are  drawn  apart. 
The  cover-glass  is  dried  in  the  air  or  over  a  Bunsen  burner  at  some 
distance  from  the  flame.  When  dry  it  is  "fixed"  by  passing  it  three 
or  four  times  through  the  flame.  Some  of  the  solution  (carbol-fuchsin, 
1;  absolute  alcohol,  10;  carbolic  acid,  5;  and  distilled  water  ad.  100) 
is  put  on  the  specimen  which  is  picked  up  with  a  Cornet  forceps  and 
held  over  the  flame  for  about  three  minutes  or  more  till  it  steams,  or 
bubbles  appear  over  it.  It  is  then  decolorized  in  a  10  per  cent,  solu- 
tion of  nitric  acid,  or  a  30  per  cent,  solution  of  sulphuric  acid  and 
washed  in  60  per  cent,  alcohol  till  it  is  completely  colorless,  when 
it  is  counterstained  with  an  alcoholic  solution  of  methylene  blue, 
washed  in  water  and  dried  between  filter  paper. 

With  Gabbet's  method  the  staining  with  carbol-fuchsin  is  the  same 
as  above,  })ut  the  decolorization  and  counterstaiiiiiig  are  done  to- 
gether by  placing  the  specimen  in  (Rabbet's  solution  (methylene  blue, 
2;    sulphuric  acid,  25;  distilled  water,  75). 


160  COUGH  AND  EXPECTORATION 

The  Hermann  stain  is  also  easy;  it  consists  in:  (a)  Crystal  violet, 
3  per  cent,  in  alcohol;  (6)  ammonium  carbonate,  1  per  cent,  solu- 
tion in  water.  Mix  one  part  of  solution  a  with  three  parts  of  solution 
h  just  before  using.  Steam  as  above,  decolorize  with  10  per  cent, 
nitric  acid,  wash  in  alcohol,  and  counterstain  with  Bismarck  brown. 
At  times  this  method  will  reveal  bacilli  when  the  above  have  failed. 

These  methods  will  disclose  the  bacilli  in  the  vast  majority  of  cases, 
but  they  fail  at  times  because  of  the  small  amount  of  sputum  avail- 
able, or  the  small  number  of  bacilli  present  in  the  specimen,  or  the 
selection  of  a  particle  of  sputum  with  the  platinum  loop  which  does 
not  contain  any  bacilli.  To  obviate  these  sources  of  error  there  have 
been  devised  new  methods  which  liquefy  the  sputum,  digest  all  the 
cells  and  bacteria  which  may  be  present,  excepting  the  tubercle 
bacilli,  which  can  be  centrifuged  and  be  examined  microscopically, 
and  may  even  be  used  for  cultural-  purposes  or  for  injections  into 
animals.  The  antiformin  method  is  at  present  the  best  and  simplest 
available  for  the  purpose. 

The  Antiformin  Method.— Devised  by  Uhlenhuth  and  Xylander, 
and  modified  by  others,  this  method  consists  in  mixing  the  sputum 
with  antiformin — a  strongly  alkaline  mixture  of  sodium  hypochlorite, 
equivalent  to  5.68  gms.  available  chlorine;  sodium  hydroxide,  7.8 
gms.,  and  sodium  carbonate,  0.32  gm. — used  by  brewers  in  the  disin- 
fection of  their  fermentation  vats  and  tubes.  When  properly  diluted 
and  mixed  with  sputum,  there  is  a  strong  liberation  of  gas,  the  insol- 
uble organic  matters,  as  well  as  bacteria,  are  destroyed,  excepting  hair, 
fat,  wax  and  cellulose,  and  acid-fast  bacilli,  the  vitality  and  staining 
reactions  of  which  remain  unchanged.  The  resulting  yellowish  solu- 
tion is  a  homogeneous  mixture  with  a  flocullent  sediment.  Because 
it  has  a  fatty  capsule  the  tubercle  bacillus  remains  intact  while  all 
other  microorganisms  are  rapidly  destroyed. 

Of  the  various  modifications  of  Uhlenhuth's  original  method,  the 
one  devised  by  Boardman^  is  the  most  serviceable.    It  consists  in: 

1.  Place  the  entire  twenty-four-hours'  sputum  in  a  conical  settling 
glass;  if  the  amount  is  excessive  it  is  perhaps  better  to  use  only  15  to 
20  c.c. 

2.  If  the  specimen  is  thick  add  an  equal  volume  of  distilled  water. 
Less  tenacious  specimens  do  not  require  so  much  dilution. 

3.  Add  an  amount  of  antiformin  equal  to  one-fourth  the  volume  of 
the  diluted  sputum;  in  other  words,  sufficient  to  make  a  20  per  cent, 
solution. 

4.  Stir  thoroughly,  thereby  breaking  up  the  masses  of  mucus  and 
greatly  hastening  complete  solution. 

5.  Allow  to  stand  till  solution  appears  homogeneous.  It  should 
now  be  watery  in  consistency  and  pale  yellow  in  color;  if  necessary, 
more  water  or  more  antiformin  should  be  added  and  digestion  allowed 

I  Johns  Hopkins  Hosp.  Bull.,  1911,  xxii,  269. 


EXAMINATION  OF  THE  SPUTUM  161 

to  continue.  This  will  usually  require  from  a  few  minutes  to  an  hour 
but  may  be  allowed  to  continue  for  days  with  no  resulting  harm  to 
the  tubercle  bacilli. 

6.  Add  an  equal  volume  of  95  per  cent,  alcohol.  By  this  procedure 
the  specific  gravity  is  reduced  from  about  1.030  to  below  1;  thereby 
not  only  hastening  sedimentation,  but  making  it  more  complete. 

7.  After  stirring,  allow  to  stand  till  sedimentation  is  complete. 
This  will  occur  in  from  two  to  four  hours,  but  a  period  of  twelve  to 
twenty-four  hours  is  recommended.  During  this  sedimentation  it 
may  be  necessary  to  gently  turn  the  vessel  to  dislodge  little  particles 
of  sediment  which  may  be  adhering  to  the  sides  of  the  vessel. 

8.  Pour  off  the  clear  supernatant  fluid. 

9.  Make  smear  from  sediment  on  a  glass  slide,  using  some  of  the 
original  sputum  to  aid  in  fixing  the  smear.  This  is  best  done  by 
making  a  smear  from  the  sputum  before  antiformin  is  added  and 
afterward  spreading  the  sediment  from  the  sputum-antif ormin  mixture 
on  the  same  slide.    Stain  in  the  usual  way. 

There  are  many  modifications  of  this  method  which  do  not  require 
twenty-four  hours  for  execution.  Loefler's  modification,  which  takes 
but  ten  minutes  is  the  best: 

A  certain  quantity  of  sputum  (10  to  20  c.c.)  is  mixed  with  an 
equal  quantity  of  50  per  cent,  aqueous  solution  of  antiformin  and 
boiled  over  the  flame.  Rapid  liquefaction  is  observed.  To  each  10 
c.c.  of  the  mixture,  1.5  c.c.  of  a  10  per  cent,  alcoholic  solution  of 
chloroform  is  added.  After  stirring  for  some  time  the  solution  is 
centrifuged  for  about  fifteen  minutes.  The  disk  which  forms  on 
the  surface  of  the  chloroform  contains  the  tubercle  bacilli,  and  is  to 
be  pipetted,  fixed  with  egg  albumen  and  stained  in  the  usual  way. 

The  great  importance  of  the  antiformin  method  lies  in  the  fact  that 
it  exerts  a  destructive  action  on  all  cells  and  microorganisms  excepting 
the  acid-fast  rods  which  may  then  be  found  microscopically.  But 
soon  after  its  introduction  it  was  found  that  the  acid-fast  rods  which 
are  not  pathogenic,  and  which  are  often  found  while  looking  for 
tubercle  bacilli,  may  escape  destruction  by  the  antiformin  thus  caus- 
ing mistakes.  Especially  was  the  question  whether  the  smegma 
bacillus  is  dissolved  by  this  agent  important.  In  a  recent  investigation 
of  this  problem  by  von  Spindler-Engelsen,^  she  found  that  the  smegma, 
the  timothy-hay  bacillus,  the  butter  bacillus,  etc.,  are  dissolved  by  15 
per  cent,  of  antiformin  in  thirty  minutes.  The  human  and  the  bovine 
types  of  tubercle  bacilli  were  not  affected  with  a  50  per  cent,  antifor- 
min solution  for  four  days.  Under  the  circumstances  it  appears  that 
the  pathogenic  bacteria  may  be  discovered  with  the  aid  of  this  method. 
It  is,  however,  important  that  a  fresh  solution  of  antiformin  should 
always  be  used,  because  a  weak  and  old  solution  may  leave  the  non- 
pathogenic bacteria  and  thus  lead  to  error. 

1  Centralblatt  f.  Bakteriologie,  1915,  Ixxvi,  356. 
11 


162  COUGH  AND  EXPECTORATION 

Much's  Granules. — ^As  has  already  been  stated  there  are  cases  of 
pulmonary  tuberculosis  in  which  no  acid-fast  bacilli  can  be  discovered 
in  the  sputum  by  any  method,  and  ]\Iuch  has  shown  that  they  are 
due  to  a  certain  kind  of  bacilli  which  have  lost  their  acid-fast  property, 
but  are  Gram-positive  and  they  retain  their  virulence.  According 
to  some  authors  these  Much  granules  are  almost  always  found  in 
cases  of  fibroid  phthisis,  chronic  bronchitis,  emphysema,  bronchiec- 
tasis, etc.,  in  which  acid-fast  bacilli  are  very  rarely  discovered  (see 
p.  18).    Much  found  them  in  cases  of  cold  abscess. 

As  to  the  causes  why  the  bacilli  lose  their  acid-fast  properties,  there 
is  no  agreement.  It  also  appears  that  the  proportion  of  cases  in  which 
they  are  found  varies  with  different  observers,  some  having  detected 
them  in  as  many  as  one  out  of  eight  sputa,  while  others  in  less  than 
2  per  cent.  Much  gives  several  methods  for  staining  these  granules. 
The  following  is  the  most  suitable: 

A  very  thin  smear  is  made  of  the  sputum  and  allowed  to  remain  for 
twenty-four  to  forty-eight  hours  in  a  methyl-violet  solution  (methyl- 
violet,  10  c.c.  of  a  saturated  solution,  in  100  c.c.  of  a  2  per  cent, 
watery  solution  of  carbolic  acid)  at  37°  C.  temperature;  or  it  may  be 
stained  by  boiling  for  a  few  minutes  over  the  flame.  Wash  and  stain 
for  one  to  five  minutes  with  Gram's  iodine  and  put  for  one  minute  in 
a  5  per  cent,  nitric  acid  solution,  then  in  a  3  per  cent,  hydrochloric 
acid  solution  for  ten  seconds,  and  finally  complete  the  decolorization 
by  placing  it  for  a  few  seconds  in  acetone-alcohol  (equal  parts  of 
acetone  and  alcohol).    Wash  and  dry. 

Prognostic  Value  of  Microscopic  Findings. — The  interest  displayed 
by  many  patients,  as  well  as  by  physicians,  in  the  number  of  bacilli 
found  in  a  specimen  of  sputum  examined  with  a  view  of  drawing  prog- 
nostic conclusions  is  unjustified.  There  are  cases  which  show  but  few 
bacilli  in  each  specimen,  yet  they  run  a  very  acute  and  progressive 
course,  while  others  with  numerous  bacilli  pursue  a  slow,  chronic  course, 
terminating  in  recovery.  Especially  is  this  seen  in  senile  phthisis, 
in  wliich  the  number  of  bacilli  expectorated  is  enormous  and  we  may, 
in  fact,  speak  of  pure  cultures;  yet  these  "bacilli  carriers"  live  on 
for  years  with  comparative  comfort.  Of  course,  in  such  cases  we 
may  deal  with  a  small  ulcerating  cavity  in  the  lung  which  ofters  good 
opportunities  for  the  growth  of  bacilli,  but  the  fibrous  capsule  pre- 
vents the  extension  of  the  lesion. 

The  number  of  bacilli  in  the  sputum  fluctuates  from  day  to  day, 
evidently  depending  to  some  extent  on  the  bit  of  sputum  we  happen 
to  pick  up  with  the  loop.  On  the  other  hand,  the  complete  absence 
of  bacilli  from  the  sputum  for  several  weeks,  coupled  with  improve- 
ment in  the  general  condition  of  the  patient,  is  undoubtedly  a  favor- 
able sign.  But  many  chronic  cases,  especially  fibroid  phthisis,  are 
always  "closed" — bacilli  are  scanty  or  absent.  With  modern  methods 
of  antiformin  examination  of  sputum  the  number  of  "closed"  cases 
have  been  reduced  verv  much. 


EXAMINATION  OF  THE  SPUTUM  163 

Inoculation. — In  very  suspicious  cases  in  which  a  diagnosis  is 
imperative,  but  the  microscopic  findings  are  negative,  inoculation  of 
the  sputum  into  guinea-pigs  may  clear  up  the  case.  The  simplest 
way  is  to  inject  it  subcutaneously  by  means  of  a  hypodermic  syringe; 
or  a  pocket  is  made  by  a  small  incision  and  the  sputum  introduced 
with  a  platinum  loop.  The  best  place  is  the  abdomen.  After  three 
weeks  the  animal  is  examined  for  enlargement  of  the  regional  lym- 
phatic glands.  If  these  are  not  found  enlarged,  the  guinea-pig  is 
killed  after  waiting  two  months,  and  if  suspicious  areas  are  found 
at  autopsy  they  are  examined  carefully.  In  most  cases  the  regional 
lymph  glands  are  enlarged  in  four  or  five  weeks  to  the  size  of  a  pea 
and  palpable.  The  animals  may  then  be  killed  with  chloroform  with 
a  view  of  more  careful  examination  at  the  autopsy. 

There  are,  however,  on  rare  occasions  cases  in  which  it  is  of  great 
importance  to  ascertain  the  presence  or  absence  of  tubercle  bacilli 
in  the  sputum  sooner  than  in  six  or  eight  weeks.  Some  have  suggested 
that  after  the  suspected  material  has  been  injected  into  the  abdominal 
wall  or  the  peritoneum,  the  animal  should  be  tested  at  frequent 
intervals  with  tuberculin.  A  positive  reaction  clears  up  the  case 
(Romer  and  Joseph).^  Martin  Jacoby  and  N.  Meyer^  suggest  that 
the  sputum  be  injected  into  a  guinea-pig  and  about  fourteen  days 
later  0.5  c.c,  of  tuberculin  should  be  injected  subcutaneously.  If 
the  sputum  contains  tubercle  bacilli  and  infects  the  animal,  it  will 
die  from  anaphylactic  shock  within  a  few  hours. 

Elastic  Fibers. — Before  the  discovery  of  the  tubercle  bacillus  great 
stress  was  laid  on  the  presence  or  absence  of  elastic  tissue  in  the 
sputum  in  the  diagnosis  of  tuberculosis,  but  of  late  this  is  only 
rarely  looked  for.  It  is,  however,  a  simple  thing  to  find  elastic  tissue 
when  present  in  the  expectoration,  and  it  is  of  immense  diagnostic 
significance  because  it  can  be  found  in  over  90  per  cent,  of  tuberculous 
sputa. 

The  presence  of  elastic  fibers  in  the  sputum  is  an  indication  of 
destruction  of  lung  tissue  and  it  may  be  found  in  the  very  early  stages 
of  the  disease,  because  chronic  tuberculosis -is  a  destructive  process 
and  small  excavations  may  be  found  quite  early  and  the  elastic  fibers 
are  not  destroyed  during  the  caseous  degeneration  which  liquefies  the 
pulmonary  tissue.  It  is  also  found  in  gangrene,  abscess,  syphilis  and 
infarction  of  the  lung,  so  that  when  the  latter  can  be  excluded,  it  may 
greatly  assist  in  the  diagnosis  of  doubtful  cases  of  tuberculosis. 

Technic. — A  small  amount  of  the  thick  purulent  portion  of  the 
sputum  is  pressed  into  a  thin  layer  between  two  pieces  of  plain  window- 
glass,  15  X  15  cm.  and  10  x  10  cm.  The  particles  of  elastic  tissue 
appear  on  a  black  background  as  grayish-yellow  spots,  and  can  be 
examined  in  situ  under  a  low  power.  Or,  the  upper  piece  of  glass  is 
slid  off  till  the  piece  of  tissue  is  uncovered,  when  it  is  picked  out  and 

1  Beilr.  z.  Klinik  d.  Tuljcrkulo.se,  19(M),  xiv,  1. 

2  Ibid.,  1911,  XX,  263. 


164  COUGH  AND  EXPECTORATION 

examined  on  a  slide,  first  with  a  low  and  then  with  a  high  power 
(Simon) . 

A  simpler  method  is  the  following:  A  bit  of  purulent  sputum  and 
a  drop  of  10  per  cent,  solution  of  sodium  or  potassium  hydrate  are 
placed  between  a  cover-glass  and  a  slide  and  examined  with  a  moder- 
ate power  under  the  microscope.  The  elastic  tissue  is  to  be  looked 
for  especially  at  the  border  of  the  preparation. 

If  the  fibers  are  scanty  they  may  not  be  found  in  this  way,  and  the 
following  method  may  reveal  them:  The  sputum  is  boiled  with  a 
10  per  cent,  solution  of  KHO  and  well  stirred  during  the  boiling. 
When  a  homogeneous  mixture  is  obtained  it  is  diluted  with  four 
times  as  much  water,  well  shaken,  and  allowed  to  stand  in  a  conical 
glass,  or  centrifuged.  The  sediment  contains  all  the  elastic  tissue 
which  may  be  found  under  the  microscope. 

The  different  methods  of  staining  elastic  tissue  are  not  necessary 
because  either  of  the  above  methods  is  sufficient  for  diagnostic  purposes. 


Fig.  20. — Elastic  fibers  in  the  sputum,     (v.  Jaksch.) 

Cytology  of  Sputum. — Various  attempts  have  been  made  to  assign 
diagnostic  and  prognostic  significance  to  the  cytology  of  tuberculous 
sputum,  especially  to  the  leukocytes  and  lymphocytes,  but  without 
avail.  Nothing  diagnostically  important  can  be  learned  from  a 
study  of  the  white-blood  cells  in  the  sputum,  as  far  as  we  know  at 
present. 

Chemical  Examination. — The  chemistry  of  the  sputum  in  pulmo- 
nary tuberculosis  has  not  yielded  any  important  diagnostic  or  prog- 
nostic data,  excepting  the  albumin  reaction  which  is  of  immense  value 
in  doubtful  cases  and  is  often  of  assistance  when  the  microscope  fails 
to  reveal  tubercle  bacilli.  Sputum  with  a  positive  albumin  reaction 
can  be  found  in  tuberculosis  and  also  in  cases  of  ])ulmonary  emphysema 
with  cardiac  dilatation,  pneumonia,  i)lcurisy  with  eifusion,  etc.,  })ut 
never  in  uncomplicated  bronchitis. 

A  positive  albumin  reaction  is  not  always  decisive  of  tuberculosis, 
but  the  negative  outcome,  when  persistent  during  several  examina- 


EXAMINATION  OF  THE  SPUTUM  165 

tions,  undoubtedly  excludes  phthisis.^  In  some  cases  of  advanced 
tuberculosis,  especially  fibroid  phthisis,  the  albumin  reaction  is  nega- 
tive, but  in  such  cases  the  diagnosis  is  only  rarely  a  problem.  It  also 
appears  that  with  the  improvement  in  the  condition  of  the  average 
patient,  the  amount  of  albumin  in  the  sputum  decreases  and  finally 
it  disappears.    It  is  thus  of  prognostic  value. 

Technic. — The  albumin  test  is  made  as  follows:  A  3  per  cent, 
solution  of  acetic  acid  is  added  to  the  sputum,  which  is  then  thor- 
oughly shaken.  During  ten  or  fifteen  minutes  the  bottle  is  allowed 
to  stand,  and  repeatedly  shaken  during  this  time.  It  will  be  observed 
that  the  mucus  is  coagulated  by  the  acetic  acid,  and  when  it  is  then 
filtered  through  paper  into  a  test  tube,  the  filtrate  appears  as  a  clear 
fluid.  Occasionally  all  the  mucus  is  not  coagulated  with  the  first 
attempt  and  this  is  easily  ascertained  by  adding  a  drop  of  acetic  acid 
to  the  filtrate,  which  in  such  cases  again  shows  flocculi  collecting  as 
a  precipitate.  The  process  is  then  repeated  until  a  clear  filtrate  is 
obtained.  The  clear  fluid  is  next  boiled  over  a  Bunsen  burner  or  an 
alcohol  lamp  and  while  boiling  some  crystals  of  common  salt,  or  a 
concentrated  solution  of  sodium  chloride,  are  added. 

If  albumin  is  present,  there  results  a  cloudiness,  or  a  curdy  pre- 
cipitate which,  on  standing,  settles  to  the  bottom  of  the  tube. 
Roughly  speaking,  the  amount  of  the  precipitate  gives  an  idea  of  the 
amount  of  albumin  present.  The  most  important  precaution  to  be 
observed  is  that  nothing  but  a  curdy  precipitate  should  be  considered 
as  positive,  because  the  presence  of  mucus,  which  the  acetic  acid  does 
not  always  completely  dissolve,  may  also  give  a  cloudy  precipitate  on 
boiling.  But  this  reaction  is  not  curdy,  nor  does  it  settle  on  standing. 
Of  course,  any  other  test  for  albumin  may  be  used  on  the  filtrate,  but 
the  above  gives  satisfactory  results. 

1  Fishberg,  Med.  Press  and  Circular,  1912,  xciv,  352;   Arch,  of  Diag.,  1912,  v,  220. 


CHAPTER  IX. 
FEVER  AND  NIGHTSWEATS. 

FEVER. 

Fever  is  one  of  the  first  symptoms  of  active  phthisis — perhaps  the 
first.  It  does  not  run  a  characteristic  course  in  every  case  hke  that 
in  malaria,  pneumonia  or  typhoid  fever;  in  fact,  its  polymorphism  is 
noteworthy.  Yet  it  is  of  immense  diagnostic  and  prognostic  value. 
Some  authors  state  that  the  fever  in  incipient  tuberculosis  is  invari- 
ably due  to  some  complication.  But  the  tuberculin  reaction,  as  well 
as  acute  miliary  tuberculosis  show  clearly  that  this  view  is  incorrect. 
All  the  available  evidence  combines  to  prove  that  it  is  due  to  absorp- 
tion of  the  poisons  produced  by  the  tubercle  bacilli,  though  it  may  be 
modified  by  mixed  infections.  The  fever  is  engendered  mainly  by 
the  increased  production  of  heat — the  result  of  complex  chemical 
processes  having  their  origin  in  the  struggle  of  the  organism  with  the 
bacilli;  the  body  summoning  its  defensive  forces  against  the  toxins 
produced  by  the  decaying  tissues.  These  latter  stimulate  the  heat 
regulating  centre.  This  is  confirmed  by  the  fact  that  nervous  indi- 
viduals are  more  apt  to  have  fever  than  others,  and  after  mental 
excitement  the  fever  often  rises  in  the  tuberculous  patient.  In  eval- 
uating the  significance  of  fever  in  tuberculosis  it  must  be  borne  in 
mind  that  it  is  not  the  cause  of  the  disease,  but  a  result  of  its  activity. 

Fever  is  present  in  nearly  all  cases  of  active  disease.  In  the  later 
stages,  especially  in  fibroid  phthisis,  we  often  meet  with  afebrile  per- 
iods of  shorter  or  longer  duration,  but  with  each  exacerbation  of  the 
disease,  with  each  extension  of  the  process  in  the  lungs  there  is  always 
a  pronounced  rise  in  the  temperature  which  should  be  studied  if  the 
evolution  of  the  case  is  to  be  followed. 

Thermometers. — The  reason  why  there  are  found  so  many  apyretic 
cases  of  phthisis  is  mainly  faulty  technic  in  taking  the  temperature, 
especially  defective  thermometers. 

The  clinical  thermometer  is  an  instrument  of  precision  and  when 
used  for  the  purpose  of  ascertaining  the  temperature  in  incipient 
phthisis,  in  which  1°  is  occasionally  of  immense  importance  in  diag- 
nosis and  prognosis,  it  must  be  accurate.  It  is,  however,  a  well-known 
fact  that,  despite  the  certified  accuracy  of  each  instrument,  simul- 
taneous observations  made  on  a  single  patient  with  two  instruments 
often  disclose  a  difference  in  readings  of  0.75°  to  2°.  The  simul- 
taneous immersion  of  two  dozen  thermometers  in  a  bath  of  warm 
water  disclosed  that  the  readings  varied  from  98.2°  to  101 .6°  F. ;  another 


FEVER  167 

similar  batch  of  higher-priced  thermometers  in  another  bath  showed 
variations  of  temperatiu'e  between  98°  and  105.4°  F.^  "Certified" 
thermometers  in  this  country  are  not  much  better.  Bray^  reports 
that  out  of  a  series  of  83  certified  thermometers  tested  in  a  water- 
bath,  17  showed  a  variation  of  0.3°  to  0.6°  F.  Comparative  rectal 
readings  approximated  closely  the  discrepancies  shown  in  the  water- 
bath.  The  presence  or  absence  of  fever,  when  such  thermometers  are 
used  to  ascertain  it,  depends  on  the  instrument  which  the  physician 
happens  to  possess  and  not  at  all  on  the  condition  of  the  patient. 
Under  the  circumstances,  it  is  clear  that  when  searching  for  fever 
in  tuberculous  patients  or  suspects,  the  instruments  must  be  reliable 
and  of  tested  accuracy,  otherwise  grave  diagnostic  mistakes  of 
omission  or  commission  are  likely  to  occur. 

Technic  of  Taking  the  Temperature. — After  having  a  good  ther- 
mometer, we  must  exercise  great  care  in  the  method  of  taking  the  tem- 
perature. I  have  been  so  often  misled  by  readings  taken  in  the  axilla, 
sometimes  finding  it  as  much  as  3°  below  that  recorded  in  the  rectum, 
that  I  now  completely  discard  it.  And,  strange  to  say,  I  meet  with 
no  patients  who  refuse  to  take  their  temperature  per  rectum.  It  has 
been  found  that  in  some  cases  the  temperature  in  the  axilla  is  higher 
on  the  affected  side  and  urged  as  a  good  sign  of  phthisis,  but  it  is  so 
rare  that  it  may  be  disregarded. 

The  mouth  temperature  is  also  unreliable  to  a  certain  extent. 
Here  it  is  influenced  by  the  temperature  of  the  external  air  which 
must  be  inhaled  now  and  then,  especially  by  patients  suffering  from 
nasal  obstruction.  The  part  of  the  instrument  outside  the  lips,  and 
at  times  also  the  part  within  the  mouth,  are  chilled  by  the  external 
air,  more  often  in  dyspneic  patients.  The  instrument  must  be  left 
in  the  mouth  at  least  seven  minutes,  and  it  often  takes  at  least  ten 
minutes  before  the  mercury  rises  to  the  highest  point,  even  with  the 
so-called  "minute  thermometers."  On  the  other  hand,  in  patients 
suffering  from  stomatitis,  the  local  temperature  may  be  much  higher 
than  that  of  the  blood.  The  temperature  in  the  mouth  should  also 
not  be  taken  immediately  after  meals,  after  taking  hot  or  cold  drinks, 
after  washing  the  mouth  or  brushing  the  teeth,  etc.  Many  patients 
also  are  unable  to  keep  the  thermometer  properly  beneath  the  tongue, 
all  surrounded  by  buccal  mucous  membrane,  and  avoid  breathing 
through  the  mouth  or  talking  for  five  to  ten  minutes. 

It  appears  that  the  majority  of  physicians  in  sanatoriums  are  in 
favor  of  oral  readings  because  they  are  dealing  with  patients  who 
practically  always  associate  in  groups  and  cannot  use  the  rectal 
method  unless  they  retire  to  their  rooms  for  the  purpose  several  times 
a  day.  This  drawback  does  not  hold  with  bed-ridden  patients,  and 
also  with  the  average  clientele  in  the  city.  In  fact,  I  found  that 
suspects,  who  keep  at  their  work  while  under  medical  observation, 

1  Lancet,  October  4,  1913;    November  8,  1913,  p.  1342. 

2  Amer.  .Jour.  Med.  Sci.,  1915,  cxli-c,  8.38. 


168 


FEVER  AND  NIGHTSWEATS 


prefer  the  rectal  method  which  they  take  in  the  lavatory  and  thus 
obviate  observation  by  others.  In  my  hospital  work  also,  there  is 
no  trouble  in  taking  rectal  temperature  in  walking  patients. 

That  the  rectal  method  is  superior  and  less  likely  to  mislead  is  now 
acknowledged  by  all  w^ho  have  given  both  methods  a  trial.  In  the 
rectum  or  vagina  the  instrument  is  on  all  sides  surrounded  by  mucous 
membrane,  holding  it  in  place  as  long  as  necessary  and  giving  reliable 
readings.  It  has  been  found  that  the  rectal  is  almost  invariably 
0.5°  to  1°  F.  higher  than  the  mouth  temperature  (Fig.  21).  It  is 
needless  to  add  that  the  instrument  is  to  be  left  in  the  rectum  suffi- 
ciently long  to  obtain  the  maximum  reading.  In  my  instructions  to 
patients  and  nurses,  I  tell  them  that  I  do  not  know  of  any  one-minute 
thermometer,  and  all  are  to  be  left  m  situ  at  least  five  minutes. 

Frequency  of  Taking  the  Temperature. — The  habit  of  many  physi- 
cians of  taking  the  temperature  when  the  patient  visits  them  and 


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Fig.  21. — Comparative  oral  and  rectal  readings  of  temperature.     (Bray.) 


recording  it  as  normal  or  elevated  to  a  certain  degree  is  altogether 
wrong.  In  incipient  or  doubtful  cases  taking  three  readings  a  day  may 
be  misleading  at  times  because  rises  in  temperature  which  occur  late  at 
night  or  early  in  the  afternoon,  and  are  short-lived,  may  thus  be  over- 
looked and  the  patient  pronounced  free  from  fever.  For  reasons  which 
will  soon  be  evident,  we  must,  in  incipient  cases,  have  a  record  of  the 
temperature  taken  every  two  hours,  and  this  is  best  recorded  by 
plotting  a  curve  on  a  chart  which  shows  graphically  any  hypothermia 
or  hyperthermia. 

Intelligent  patients  may  be  entrusted  with  a  thermometer,  pro- 
vided they  are  trained  in  reading  it  correctly,  which  can  be  done  in  a 
few  minutes.  I  have  had  patients  who  kept  records  of  their  two- 
hourly  temperature  for  weeks  and,  for  obvious  reasons,  more  con- 
scientiously than  the  average  nurse.  jNIany  have  done  it  without 
leaving  their  occupations  by  simply  going  to  the  lavatory  every  two 
hours  for  five  minutes. 


FEVER 


169 


The  Normal  Temperature.— It  may  be  stated  that  the  normal 
temperature  in  children  is  not  a  constant  value.  It  is  subject  to  such 
oscillations  during  perfect  health,  that  any  average  which  has  been 
fixed  by  various  authors  is  only  arbitrary.  The  slightest  disturbance 
in  health  is  likely  to  increase  the  temperature  in  the  child  to  a  greater 
degree  than  in  the  adult.  Many  clinicians  consider  a  temperature 
of  100°  to  101°  F.  normal  in  a  child,  unless  there  are  symptoms  of 
disease.  But  with  advancing  age  the  temperature  becomes  more  and 
more  settled,  so  that  in  adults  it  is  subject  to  lesser  oscillations,  unless 
raised  or  depressed  by  disease. 

As  an  arbitrary  guide  for  the  chnician  it  may  be  taken  that  a 
temperature  of  98.6°  F.  when  taken  by  mouth,  and  0.5°  higher  when 
taken  by  the  rectum,  is  normal.  But  even  this  shows  striking  diurnal 
variations  in  normal  individuals.  During  the  early  morning  hours, 
before  the  individual  leaves  his  bed,  it  is  slightly  subnormal  from  0.5° 
to  1  ° ;   but  it  rises  to  normal  soon  after  rising,  and  keeps  quite  steady 


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Fig.  22. — Fever  in  incipient  tuberculosis  showing  marked  subnormal  temperature 
in  the  early  morning  hours.    Temperature  taken  twice  daily. 

during  the  day.  Bardswell  and  Chapman^  found  an  average  for 
waking  hours  98.5°  F.,  and  for  sleeping  hours  97.2°  F.,  taken  by  mouth, 
which  is  in  agreement  with  the  observations  of  most  physicians. 

There  are,  however,  individuals  in  whom  the  temperature  is  lower 
than  the  above  average  and  in  whom  a  physiological  normal  tempera- 
ture should  be  considered  febrile.  This  is  occasionally  seen  in  tubercu- 
lous patients  w^ith  subnormal  temperature;  when  the  thermometer 
registers  99°  F.  they  present  symptoms  of  fever,  such  as  flushing, 
hot  skin,  headache,  etc. 

Normally  the  temperature  is  elevated  in  persons  after  exercise,  and 
in  some  even  after  a  hearty  meal.  In  women  it  may  be  higher  by  1°  or 
2°  before  or  during  menstruation.  But  the  elevation  after  exercise 
is,  in  the  healthy  individual,  evanescent;  within  one-half  to  one  hour 
it  sinks  again  to  normal. 


1  Brit.  Med.  Jour.,  1911,  i,  1106. 


170  FEVER  AND  NIGHTSWEATS 

Other  influences  which  should  be  mentioned  are  the  emotional 
state  of  the  individual.  Particularly  in  women,  excitement  may  raise 
the  temperature  1°  to  2°.  Where  there  is  a  question  of  tuberculosis, 
the  excitement  attending  the  taking  the  temperature  may  be  effec- 
tive in  raising  it,  as  I  have  seen  in  several  cases,  and  we  must  be 
very  careful  in  making  a  diagnosis  of  incipient  phthisis  on  the 
thermometrical  readings  alone  in  emotional  women. 

In  some  people  who  w^ork  during  the  night  and  sleep  during  the 
day,  the  variations  in  temperature  mentioned  above  are  said  to  be 
reversed. 

In  evaluating  thermometrical  findings  in  suspected  incipient  phthisis 
we  are  on  safe  ground  when  we  consider  the  normal  temperature  dur- 
ing the  day  in  a  person  who  works  or  w^alks  around  as  99°  F.  when 
taken  per  rectum,  and  0.5°  to  0.75°  lower  when  taken  by  mouth.  It 
may  be  0.5°  to  1°  lower  in  the  morning  before  rising,  and  0.5°  higher 
in  the  evening  after  a  heavy  meal,  or  after  a  hard  day's  work.  Dis- 
tinct variations  from  these  figures  demand  explanation,  and  if  no 
other  cause  is  found  tuberculosis  is  to  be  considered  as  the  possible 
cause. 

Fever  in  the  Incipient  Stage. — ^\Vhen  taken  with  due  precautions 
it  will  be  found  that  a  subfebrile  or  febrile  temperature  is  character- 
istic of  the  evolution  of  active  phthisis  even  in  the  incipient  stage,  and 
that  the  absence  of  fever  excludes  active  disease.  The  afebrile  cases 
of  phthisis  mentioned  by  physicians  are  mostly  the  result  of  faulty 
technic  in  taking  the  temperature.  Evanescent  rises  are  overlooked. 
Moreover,  in  these  cases  the  instability  of  the  temperature  could  be 
determined  by  ordering  the  patient  to  take  some  exercise.  An  eleva- 
tion of  0.5°  to  1.5°  in  the  afternoon  or  after  some  excitement,  or 
exertion,  lasting  about  half  an  hour  may  be  observed  in  some  persons 
who  have  no  tuberculosis,  as  w^as  mentioned  above;  with  the  phthis- 
ical, however,  it  is  more  lasting.  It  appears  that  a  large  proportion 
of  patients  with  early  tuberculosis  have  a  subnormal  temperature  in 
the  early  morning  hours,  some  recording  as  low  as  96°  F.,  before 
getting  out  of  bed. 

When  interpreting  fever  in  the  early  stages  of  phthisis,  we  should 
follow  Daremberg's^  suggestion  and  consider  the  difference  between 
the  highest  and  lowest  temperature.  Thus,  a  patient  with  a  tem- 
perature of  99.8°  F.  at  5  p.m.  has  not  only  1°  above  normal  when 
his  morning  temperature  is  96.5°  F.,  but  3.3°  above  normal  and  should 
be  considered  febrile,  and  when  prolonged  for  some  time,  it  is  un- 
doubtedly of  tuberculous  origin,  unless  some  other  cause  is  found. 

Symptoms  of  Fever. — These  afternoon  rises  can  also  be  distin- 
guished from  other  rises  and  from  physiological  elevations  by  the 
concomitant  symptoms  which  are  met  with  in  most  cases  of  incipient 
phthisis.    In  the  latter  there  is  an  acceleration  of  the  pulse  rate  far 

'  Tuberculoso  Pulmonairc,  Paris,  1905,  p.  59. 


FEVER 


17 


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172  FEVER  AND  NIGHTSWEATS 

out  of  proportion  to  the  slight  elevation  of  temperature.  Many  also 
have  mild  chilly  sensations,  or  even  a  distinct  chill  about  an  hour 
before  the  rise  in  temperature,  when  the  face  is  pale  and  the  extrem- 
ities feel  cold.  Later  the  face  becomes  flushed,  the  eyes  brighten 
with  characteristic  brilliancy,  which  can  often  be  recognized  by  the 
experienced  observer  and  the  patient  feels  warm  or  hot,  tired,  fatigued 
and  disinclined  to  work,  and  has  some  headache.  It  is  noteworthy 
that  despite  all  these  symptoms  the  appetite  for  the  evening  meal 
is  not  diminished,  which  is  not,  as  a  rule,  observed  in  fever  due  to  other 
causes.  Anorexia  is  a  constant  accompaniment  of  fever,  excepting 
the  fever  of  early  phthisis.  This  tolerance  of  fever  of  the  tuberculous 
manifests  itself  also  in  their  aptitude  to  work  during  the  day  and  sleep 
during  the  night  as  if  they  were  well,  feeling  only  somewhat  tired 
or  languid,  when  the  thermometer  reads  101°  F.  or  more.  Finally, 
during  the  night  more  or  less  sweating  may  occur,  which  even  in  early 
cases  may  be  so  profuse  as  to  drench  the  patient. 

Subjective  Fever  without  Elevation  of  Temperature. — These  symp- 
toms, in  varying  degrees  of  severity,  are  only  rarely  absent  in  incipient 
phthisis  and  they  are  excellent  guides  in  our  attempts  at  excluding 
rises  in  temperature  due  to  other  causes.  In  fact,  the  afternoon 
languor  just  mentioned  is  so  characteristic  of  the  toxic  state  of  the 
tuberculous  that  we  often  meet  it  in  some  advanced  cases — notably, 
fibroid  phthisis — which  are  afebrile.  In  such  cases  we  may  speak  of 
subjective  fever  without  elevation  of  temperature,  first  described  by 
Dettweiler.  I  have  seen  it  in  a  few  cases  of  incipient  tuberculosis. 
For  this  reason  we  must  not  rely  solely  on  thermometry  while  treat- 
ing tuberculous  patients.  Conversely,  fever  without  subjective  symp- 
toms is  occasionally,  though  very  rarely,  seen  in  incipient  cases  and 
the  prognosis  is  very  good  indeed. 

Provoked  Fever. — ^The  heat  centre  is  apparently  easUy  disturbed 
in  phthisis  and  as  a  result  we  have  usually  a  labile  or  unstable  tem- 
perature. Conditions  which  in  the  average  normal  individual  have 
no  effect  on  the  temperature  may  elevate  it  in  the  consumptive.  Thus, 
a  heavy  meal,  moderate  exertion,  emotional  disturbances  hke  reading 
or  writing  a  letter,  worry,  anxiety  and  excitement,  especially  during 
the  early  morning  hours,  may  raise  the  temperature  from  1.5°  to  3°  F. 
and  more.  I  have  seen  the  excitement  of  a  medical  examination  raise 
the  temperature  of  a  patient  in  my  office  3.5°  within  one-half  hour,  and 
in  European  sanatoriums  it  is  a  routine  measure  to  inject  water  at 
the  beginning  of  a  tuberculin  treatment  with  a  view  of  ascertaining 
whether  the  febrile  reaction  is  really  due  to  the  tuberculin  or  to 
emotional  disturbances.  On  visiting  days  in  sanatoriums  a  large 
proportion  of  patients  have  higher  fever  than  on  other  days.^  It  has 
also  been  observed  that  a  change  in  residence,  as  the  admission  into 
an  institution,  a  railway  journey,  giving  a  sanatorium  patient  leave  to 
spend  a  day  with  his  family,  etc.,  may  elevate  the  temperature  of  the 
consumptive. 


FEVER 


173 


This  fievre  prowquee,  first  described  by  Daremberg,  and  then  again 
by  Penzoldt/  can  be  utihzed  for  diagnostic  purposes  in  cases  sus- 
pected of  incipient  phthisis.  When  we  have  a  patient  presenting 
indefinite  symptoms  and  signs  of  tuberculosis  but  the  temperature 
is  normal,  we  may  take  the  temperature  before  and  after  active  exer- 
cise, and  if  it  is  raised  1°  F.  or  more,  we  are  probably  dealing  with  a 
case  of  incipient  tuberculosis.  The  usual  rule  is  to  let  the  patient 
walk  about  two  miles  and  note  the  effect.  My  way  has  been  to  ask  the 
patient  to  take  his  rectal  temperature  before  he  starts  out  for  my 
office,  and  then  walk  one  and  a  half  or  two  miles  while  coming.  Im- 
mediately on  his  arrival  his  temperature  is  again  taken,  preferably 
with  the  same  thermometer. 

A  rise  of  1°  or  more  in  the  temperature  after  such  a  test  is  higlily 
suspicious  of  tuberculosis;  Daremberg  insists  that  it  is  conclusive. 
Combined  with  other  symptoms  and  signs,  it  is  undoubtedly  of  great 
value.     But  in  obese  persons    this  may  be  observed  without  any 


DAYS 


10111  12!l3:14:15  16  171819  20  21,22  23  24  25  26 -iT'SS  29301  1    23j4    56789   10 


Fig.  24. — Female,  aged  nineteen  years.    Premenstrual  fever  in  an  afebrile  case  of 
incipient  tuberculosis.     (Bray.) 

tuberculous  lesions  in  their  lungs  and  the  same  is  true  of  anemic, 
especially  chlorotic  young  women.  But  in  physiological  rises  after 
exercise  the  elevated  temperature  again  sinks  to  normal  within  half 
an  hour  of  rest,  while  in  the  tuberculous  it  lasts  much  longer,  two 
hours  or  even  more. 

Menstrual  Fever. — In  women  the  fever  may  be  more  accentuated 
during  the  menstrual  period,  which  at  times  is  of  diagnostic  impor- 
tance (Fig.  24).  We  must,  however,  remember  that  in  many  non- 
tuberculous  women  slight  elevations  of  temperature  are  observed  a 
few  days  before  or  during  that  period.  But  in  the  phthisical  we  meet 
not  only  with  elevation  of  temperature,  but  occasionally  also  with  an 
increase  in  the  number  of  rales  over  the  site  of  the  lesion,  hemoptysis 
and  pleuritic  pains.  Macht^  says  that  "the  rise  in  temperature  may 
occur  in  afebrile  patients,  that  is,  patients  who  ordinarily  run  no  fever 
as  well  as  in  those  who  run  a  slight  temperature  through  the  montli. 

1  Handbuch  der  Therapie,  Jena,  1910,  iii,  188. 
*  Amer.  Jour.  Med.  Sci.,  1910,  cxl,  835. 


174  FEVER  AND  NIGHTSWEATS 

These  rises  may  occur  in  early  cases  as  well  as  in  advanced,  and  in 
the  former  are  of  considerable  diagnostic  importance.  If  a  patient 
shows  a  constantly  recurring  menstrual  rise  in  temperature,  and 
pelvic  disease  cannot  be  found,  a  tuberculous  process  should  always 
be  borne  in  mind." 

In  most  cases  the  fever  declines  with  the  appearance  of  the  flow; 
it  may  last  several  days  or  only  a  few  hours.  Sabourin^  has  shown  that 
in  certain  women  the  menstrual  fever  lasts  three  weeks  and  leaves 
the  patient  only  one  week  before  the  onset  of  the  next  menstruation. 
In  these  cases  it  is  of  grave  importance;  the  patients  "are  killed  by 
their  courses,"  as  Sabourin  says. 

Many  authors,  notably  Yandervelde,  Sabourin,  Wiese,^  C.  A.  Welch,^ 
E.  C.  Morland,"*  and  others,  state  that  premenstrual  fever  indicates 
latent  or  active  tuberculosis  and  should  be  given  attention  when 
attempting  to  make  a  diagnosis  in  doubtful  cases.  This  premen- 
strual fever  occurs  a  few  days  before  the  onset  of  menstruation  and 
may  continue  throughout  the  days  of  the  flow.  Considering  that  it 
has  been  found  that  in  from  40  to  50  per  cent,  of  tuberculous  women 
there  is  hyperthermia  before  and  during  that  period,  while  in  healthy 
women  the  percentage  is  considerable  less,  these  authors  maintain 
that  it  is  of  immense  diagnostic  value,  and  that  the  absence  of  men- 
strual fever  excludes  active  tuberculosis. 

According  to  Macht,  these  rises  in  temperature,  when  reaching 
high,  are  an  evil  omen  prognostically;  on  the  other  hand,  if  they  ^row 
less,  or  disappear  altogether,  it  is  a  sign  of  a  cured  or  an  arrested 
condition. 

Evaluation  of  Fever  in  Tuberculosis. — ^In  the  usual  case  of  chronic 
phthisis  in  the  incipient  stage  there  is  a  subfebrile  temperature  which 
is  often  overlooked  unless  the  thermometer  is  used  every  two  hours 
for  a  week  or  two.  The  feeling  of  languor  which  overtakes  the  patient 
during  the  afternoon  is  often  taken  as  an  indication  of  neurasthenia, 
the  anorexia  is  attributed  to  dyspepsia,  and  the  real  cause  over- 
looked. From  Fig.  25  it  will  be  seen  that  if  in  this  case  the  tem- 
perature had  been  taken  only  at  8  a.m.,  12  m.,  and  8  p.m.,  as  is  usually 
done,  the  febrile  reaction  at  three  to  six  would  have  been  overlooked, 
and  the  patient  pronounced  afebrile.  In  rare  cases,  these  febrile 
reactions  occur  during  the  night  and  thus  escape  detection.  Still 
rarer  is  the  so-called  "reversed  type"  of  fever,  the  febrile  reaction 
occurring  during  the  early  morning  hours.  It  appears  that  the  ])rog- 
uosis  is  unfavorable  in  the  last  class  of  cases. 

Since  a  subfebrile  temperature  for  one  or  two  days  is  no  conclusive 
proof  of  the  existence  of  active  phthisis,  because  such  ephemeral 
hyperthermia  may  be  due  to  other  causes,  and  also  because  there 

'  Revue  dc  .Medccinc,  1905,  xxv,  175. 

2Beitr.  z.  Klitiik  d.  Tulx-rkuloso,  1912,  xxvi,  .S35. 

'Lancet,  1910,  i,  039. 

"Ibid.,  S21. 


FEVER 


175 


are  afebrile  days  during  the  incipient  stage  of  phthisis,  the  tempera- 
ture should  be  taken  continuously  for  two  or  three  weeks  in  doubtful 
cases  before  arriving  at  a  conclusion.  The  readings  thus  plotted  on 
the  chart  are  the  best  graphic  criteria  for  diagnosis. 

The  slight  afternoon  rises  in  temperature  characteristic  of  incipient 
phthisis  are  not  exclusively  met  with  in  this  disease;  there  are  other 
conditions  which  may  produce  hyperthermia  for  weeks,  greatly  sim- 
ulating phthisis.  For  this  reason  we  must  not  hastily  decide  in  favor 
of  this  disease  unless  there  are  other  symptoms  and  signs  of  lung 
disease.  I  have  had  under  my  care  a  woman  who  was  treated  for 
several  months  in  a  sanatorium,  then  handed  over  to  surgeons  for  opera- 
tion for  gall-stones,  and  while  convalescing  after  the  operation  another 
diagnosis  of  tuberculosis  was  made.  The  woman  was  then  admitted 
under  my  care  and  for  three  months  the  afternoon  temperature  w^as 
almost  invariably  elevated  1°  to  3°.     We  finally  gave  her  work  as  a 


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Fig.  2.5. — Incipient  phthisis,  active  lesions  in  left  apex.  Temperature  taken  every 
three  hours  (black  line)  shows  daily  exacerbations  of  the  fever  reaching  102°  F.  in  the 
afternoon.  This  exacerbation  would  be  missed  if  temperature  was  only  taken  three 
times  a  day,  at  8  a.m.,  12  m.,  and  7  p.m.,  as  is  shown  by  dotted  curve. 


nurse  and  she  worked  during  the  succeeding  six  months  quite  hard 
and  has  not  developed  phthisis,  nor  .shown  any  indications  of  the 
disease  on  physical  exploration  of  the  chest.  She  still  has  an  elevated 
temperature  every  afternoon.  These  afternoon  rises  in  temperature, 
when  not  due  to  tuberculosis,  are  mainly  found  in  women.  Anemia, 
especially  chlorosis,  and  occasionally  pernicious  anemia  may  be  the 
cause.  However,  an  examination  of  the  blood  clears  up  the  case. 
Purulent  conditions  of  the  nose  and  accessory  sinuses,  chronic  inflam- 
matory conditions  of  the  tonsils,  non-tuberculous  bronchiectasis, 
pyelitis,  diseases  of  the  female  genitalia,  etc.,  may  be  accompanied 
by  subfebrile  temperature.  These  are  but  a  few  of  the  conditions  which 
must  be  looked  for  in  doubtful  cases. 

After  all,  purely  hysterical  fe\'er  must  be  borne  in  mind  when 
everything  else  has  been  ruled  out.  There  is  no  question  ))ut  that  it 
does  occur,  although  our  modern  views  of  the  pathogenesis  of  fever 


176 


FEVER  AND  NIGHTSWEATS 


are  against  it.  This  appears  to  be  one  of  the  many  paradoxes  in 
chnical  medicine. 

In  evaluating  the  significance  of  the  temperature  range  in  active 
phthisis,  we  may  be  guided  by  the  rules  laid  down  by  Harris  and  Beale:^ 
The  higher  the  day  temperature,  the  more  active  the  disease,  except 
in  a  few  rare  instances  (the  so-called  "reverse  type")  where  the 
ordinary  fluctuations  are  reversed,  and  the  night  temperature  remains 
lowest  throughout  the  whole  course  of  the  disease.  But  whether 
the  norma)  or  the  inverted  remissions  take  place,  the  lowest  tem- 
perature is  always  high,  and  so  long  as  it  follows  this  course,  it 
may  be  assumed  that  active  deposition  of  tubercle  is  taking  place, 
even  though  the  physical  signs  remain  for  the  time  unaltered. 

Most  patients  with  fever  lose  in  weight,  but  there  are  many  excep- 
tions, and  patients  as  well  as  physicians  are  apt  to  judge  a  case  more 
by  the  scale  than  by  the  thermometer.  This  is  wrong.  There  are  cases 
of  phthisis,  especially  those  in  whom  the  fastigium  occurs  during  the 
night,  that  remain  stationary  or  gain  in  weight  while  the  process  in 
the  lungs  keeps  on  progressing.     In  other  words,  neither  fever,  nor 


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Fig.  26. — Fever  in  incipient  tuberculosis.     Temperature  taken  every  three  hours. 

the  weight  alone  should  be  taken  as  a  criterion  for  prognosis,  but 
all  the  concomitant  symptoms  and  signs  should  be  considered  in 
this  connection. 

On  the  other  hand,  the  absence  of  pyrexia,  while  a  good  sign  in 
most  cases,  is  not  conclusive  evidence  of  the  mildness  of  the  process, 
especially  when  other  symptoms  of  active  disease  are  present.  I 
have  seen  many  patients  in  whom  the  temperature  never  exceeded 
101°  F.,  or  was  even  less,  still  the  anorexia,  emaciation,  cough,  hemop- 
tysis, etc.,  were  all  active  in  bringing  them  to  a  fatal  termination. 
This  is  especially  seen  in  cases  which  have  lasted  for  some  years.  The 
organism  has  adapted  itself  to  the  disease  and  does  not  react  any 
more  to  the  same  degree  that  it  does  usually,  and  its  defensive  forces 
are  in  abeyance.  It  may  be  seen  with  any  lesion,  not  excluding  large, 
but  usually  dry,  cavities  in  the  lungs. 

Types  of  Fever  in  Chronic  Tuberculosis. — In  progressive  and  also 
in  advanced  cases  of  phthisis  the  fever  is  not  typical,  and  a  diagnosis 

'  Treatment  of  Pulmonary  Consumption,  London,  1895,  p.  314. 


FEVER 


177 


cannot  be  made  from  an  analysis  of  the  temperature  curve  alone, 
as  is  often  the  case  in  malaria,  relapsing  fever,  typhoid,  pneumonia, 
etc.  In  phthisis  we  may  meet  with  any  type  of  hyperthermia  in  dif- 
ferent patients,  and  in  the  same  patient  at  different  times,  depending 
on  the  activity  of  the  process,  mixed  infection  with  pyogenic  organisms, 
softening  of  lung  tissue,  free  drainage  of  necrotic  foci,  etc.  Under  the 
circumstances  we  cannot  speak  of  a  typical  tuberculous  fever,  but  we 
meet  with  certain  temperature  curves  which  serve  as  good  and  reliable 
guides  in  our  attempts  at  ascertaining  the  condition  of  the  patient, 
the  presence  or  absence  of  complications,  and  esDecially  when 
attempting  to  formulate  a  prognosis. 

Continuous  Fever. — ^This  is  met  with  especially  in  cases  with  exten- 
sive pneumonic  involvement,  in  acute  pneumonic  phthisis,  and  in 
tuberculous  bronchopneumonia  in  children.  In  chronic  phthisis  which 
has  pursued  a  favorable  course,  when  a  continuous  temperature  develops 


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after  a  pulmonary  hemorrhage,  or  without  any  visible  cause,  we 
may  conclude  that  there  has  occurred  an  extension  of  the  process  in 
the  lungs;  and  if  this  high,  continuous  temperature — even  when  it  does 
not  exceed  103°  F. — lasts  more  than  three  or  four  weeks,  the  prog- 
nosis is  very  grave  and  a  fatal  issue  may  be  looked  for.  In  some  cases 
a  slight  improvement  may  occur,  but  it  is  noteworthy  that  they  are 
never    cured. 

Cyclic  Fever. — In  many  cases  of  chronic  phthisis  we  meet  cyclic 
or  undulating  types  of  hyperthermia.  The  patient  is  never  free  from 
fever,  but  for  two  or  three  days  during  the  week  the  maximum  read- 
ing reaches  102.5°  or  103.5°  F.,  or  even  more,  while  the  other  four 
or  five  days  it  is  much  lower — 100.5°  to  101.5°  F.  These  wave-like 
fluctuations  may  appear  more  or  less  periodically  for  months  and  not 
only  show  variations  during  each  week,  but  the  febrile  waves  may 
appear  at  greater  intervals,  every  two  or  three  or  four  weeks,  as  can 
12 


178 


FEVER  AND  NIGHTSWEATS 


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FEVER  179 

be  seen  from  Fig.  28.  It  is  seen  in  cases  in  which  old  foci  are  softening 
or  the  pulmonary  process  is  extending  and  each  exacerbation  of  the 
fever  is  an  expression  of  a  new  area  of  involvement  which  may  in 
many  cases  be  easily  discerned  by  a  careful  physical  exploration  of 
the  chest. 

Hectic  Fever. — In  progressive  disease  these  types  of  hyperthermia 
are  usually  followed  at  the  end  by  hectic  fever  (Fig.  29).  In  cases 
in  which  there  is  softening  in  the  lung,  the  necrotic  tissue  being 
gradually  expelled  leaving  cavities,  the  temperature  chart  tells  the 
story.  There  are  morning  remissions  during  which  the  temperature 
is  nearly  normal  or  even  subnormal,  while  in  the  afternoon  there 
may  be  a  chilly  sensation,  or  a  distinct  chill  with  chattering  of  the 
teeth;  the  pulse  which  was  rapid  and  small  during  the  apyrexial 
morning  hours,  is  even  more  accelerated,  the  temperature  begins 
to  rise  reaching  103°,  and  in  some  cases  even  105°  at  about  five  in 
the  afternoon.  The  nightsweats  in  these  cases  are  very  profuse  and 
exhausting. 

The  time  of  the  highest  fever  in  these  hectic  cases  is  variable. 
Often  the  maximum  is  attained  in  the  afternoon,  but  in  many  it  is 
around  noon  and  in  the  evening  it  may  be  normal.  If  in  such  cases  it 
is  taken  only  mornings  and  evenings,  we  may  find  a  record  of  normal 
temperature,  because  the  midday  rise,  which  may  have  been  quite 
high,  has  been  overlooked. 

This  hectic  fever  may  last  for  weeks,  or  even  for  months,  during 
which  time  the  unfortunate  patient  is  reduced  to  a  skeleton  by  the 
fever  and  the  accompanying  anorexia  and  diarrhea,  which  are  hardly 
ever  lacking.  The  frightful  appearance  of  the  bundle  of  bones  with 
hardly  any  visible  muscles,  which  have  atrophied  extremely,  covered 
by  a  clammy,  muddy  skin;  the  skin  emaciated  but  edematous  around 
the  ankles  and  knees,  the  eyes  deeply  set  in  the  orbits,  the  temples 
sunken,  is  disheartening  to  the  physician  making  his  rounds  in  the 
hospital;  he  feels  helpless  when  the  slowly  sinking,  but  still  strug- 
gling, human  being  gazes  appealingly  for  assistance  which  cannot  be 
given.  It  is  noteworthy  that  with  all  this  material  decay  the  intelli- 
gence and  often  the  hopes  and  aspirations  of  the  patient  are  well 
retained,  and  he  begs  for  the  relief  of  some  minor  and  comparatively 
insignificant  symptom  such  as  the  cough  or  diarrhea,  saying  that  if 
this  is  removed  he  will  feel  in  excellent  condition. 

At  the  terminal  stages  there  may  be  irregular  fever,  the  curve  of 
one  day  differs  from  that  of  the  other.  Saugman'  states  that  this  is 
a  good  sign  of  intestinal  tuberculosis  when  occurring  in  the  earlier 
stages  of  the  disease  (Fig.  30). 

Subnormal  Temperature. — The  subnormal  temperature  seen  in  many 
incipient  cases  during  the  morning  hours  has  already  been  mentioned. 
But  we  also  meet  with  patients  in  the  advanced  stages  of  the  disease 

1  In  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  der  Tuberkulose,  ii,  284. 


180 


FEVER  AND  NIGHTSWEATS 


who  present  subnormal  temperature  throughout  the  day  and  night 
for  weeks;  the  mercury  never  rises  above  98.5°  F.,  and  early  in  the 
day  it  may  be  as  law  as  96°  or  97°  F.  The  disease  may  be  active  and 
even  progressive,  yet  the  thermometer  gives  no  indication  of  it.  I 
have  many  of  these  cases  in  my  hospital  service.  I  find  it  is  usually 
an  indication  of  excavation,  just  as  fever  is  an  indication  of  infiltration, 
caseation,  and  softening  of  lung  tissues. 

These  cases  have  been  recently  spoken  of  by  O.  K.  Stone :^  "At 
certain  periods  of  the  disease,  usually  succeeding  the  active  febrile 
stage,  there  is  often  a  period  when  the  temperature  curve  shows  marked 
excursions  in  the  subnormal,  the  temperature  at  no  time  rising  above 
98.6°  and  rarely  fully  reaching  this  point.  The  patients  during  this 
period  of  subnormal  temperature  are  usually  improving  and  making 
distinct  gains,  but  it  takes  very  little  to  give  them  exacerbations  of 
real  temperature,  lasting  for  a  few  hours  to  a  few  days." 


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1    t    1    1    i    1    i 

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Fig.  30.— ^Irregular  fever  in  advanced  tuberculosis  of  the  lungs  with  intestinal 

complications. 


Subnormal  temperature  is  also  seen  in  fibroid  phthisis  and  emphy- 
sema complicated  by  tuberculosis,  in  both  of  which  the  disease  runs 
a  chronic,  sluggish  course.  Many  keep  disabled  for  years,  though  not 
confined  to  bed,  but  they  never  fully  recover.  A  subnormal  tem- 
perature is  also  seen  on  rare  occasions  in  a  subacute  case  of  phthisis 
which  suddenly  took  a  turn  for  the  better  after  the  necrotic  tissue  in 
the  lung  had  been  eliminated  from  that  organ  and  a  cavity  remained. 
In  this  class  recovery  may  take  place,  as  I  have  seen  on  several 
occasions. 

The  sudden  drop  in  the  temperature  combined  with  dyspnea  and 
cyanosis  in  a  febrile  case  of  phthisis  may  mean  a  spontaneous  pneumo- 
thorax, or  a  rapid  extension  of  the  necrotic  process  in  the  lung  over- 
whelming the  patient.  The  prognosis  in  either  event  is  grave  indeed. 
In  many  extremely  emaciated  consumptives  the  temperature  is  sub- 
normal for  se\'eral  days  before  death. 

1  Boston  Med.  and  Surg.  Jour.,  1914,  clxxi,  1008. 


FEVER        .  181 

Apyretic  Tuberculosis. — In  old  chronic  cases  of  phthisis  we  may 
have  a  normal  temperature  for  months,  though  the  process  in  the 
lungs  keeps  up.  This  is  seen  in  fibroid  phthisis,  in  phthisis  in  the  aged, 
and  in  tuberculous  pleurisy.  Many  of  these  patients  live  for  years  and 
do  not  lose  in  weight.  I  have  seen  such  patients  last  for  fifteen  and 
twenty  years,  always  ailing,  coughing,  expectorating,  at  times  having 
spells  of  more  or  less  profuse  hemoptysis.  They  are  the  important 
sources  of  the  dissemination  of  tubercle  bacilli;  more -so  than  most 
of  the  stormy  cases.  They  are  not  strong  enough  for  muscular  work 
but  may  be  moderately  efiicient  at  any  occupation  which  does  not 
require  undue  exertion.  We  meet  these  cases  mainly  among  the  well- 
to-do,  who  can  afford  to  lead  an  idle  life,  or  among  the  very  poor  who 
have  intrenched  themselves  in  hospitals  for  chronic  and  "incurable" 
cases  of  tuberculosis  and,  for  one  reason  or  another,  like  institutional 
life,  and  stick  to  it  for  long  periods.  We  also  meet  these  active  but 
apyretic  cases  among  the  more  cultured  classes,  who  either  know  how 
to  take  care  of  themselves  or,  being  professional  persons,  they  may 
pursue  their  vocations  with  more  or  less  efficiency.  Some  are  very 
brilliant,  and  the  type  of  consumptive  drawn  by  so  many  writers  of 
fiction  is  usually  copied  after  the  model  of  this  class  of  patients.  It 
is  noteworthy  that  while  most  of  them  are  more  or  less  emaciated,  we 
now  and  then  meet  one  who  is  actually  fat  and  may  even  be  placed 
in  the  category  of  the  obese.  They  usually  suffer  from  dyspnea 
because  of  the  fatty  heart  and  pulmonary  fibrosis. 

Phthisis  in  the  aged  also  runs  an  apyretic  course  at  times  and,  because 
they  do  not  cough  excessively,  the  disease  may  not  be  recognized. 

It  appears  that  there  are  great  differences  in  the  reactive  powers 
of  different  persons  suffering  from  phthisis.  In  some  the  fact  that 
they  have  a  normal  temperature  is  no  proof  that  the  disease  is  benign, 
especially  if  other  symptoms  of  active  disease  are  present.  I  have 
seen  patients  whose  temperatures  hardly  ever  exceeded  101°  F.,  yet 
they  wasted,  perspired,  and  had  exhausting  diarrhea;  they  finally 
died  with  a  low  temperature.  While  the  temperature  curve  is  an 
excellent  guide  as  to  the  tendencies  and  progress  of  the  disease,  these 
apyretic  cases  must  be  judged  more  by  the  general  symptoms  than  by 
the  thermometrical  findings,  as  has  already  been  shown. 

Fever  due  to  Complications. — During  the  course  of  phthisis  fluctua- 
tions in  the  temperature  usually  go  hand-in-hand  with  the  activity 
of  the  disease,  and  each  elevation  or  depression  in  the  temperature 
curve  may  be  explained  by  the  findings  in  the  chest  through  physical 
exploration.  But  there  are  exceptions.  Many  elevations  of  the  tem- 
perature are  due  to  non-tuberculous  complications.  Thus,  as  will 
be  seen  from  Fig.  31,  malaria  may  complicate  phthisis  and  produce 
confusion,  unless  the  blood  is  examined  and  the  malarial  parasite  is 
found. 

Other  complications  to  be  mentioned  are  constipation,  acute  gas- 
tritis, tonsillitis,  influenza,  pleural  effusions,  etc.     These  may  be  the 


182 


FEVER  AND  NIGHTSWEATS 


cause  of  a  sudden  elevation  of  temperature  in  a  case  in  which  the 
tuberculous  process  is  proceeding  rather  favorably.  Careful  examina- 
tion usually  reveals  the  cause  of  the  pyrexia. 

A  rise  in  the  temperature  in  a  tuberculous  patient  may  be  due  to 
the  administration  of  certain  drugs,  mostly  of  the  sedative  and  hyp- 
notic class,  as  has  been  pointed  out  by  Sabourin^  and  Mantoux.^  I 
have  repeatedly  observed  that  after  the  administration  of  opium  or  its 
derivatives,  morphin,  codein,  heroin,  dionin,  etc.,  or  chloral,  sulfonal, 
trional,  etc.,  there  is  often  a  rise  in  the  temperature  during  the  suc- 
ceeding twenty-four  hours.  A  rise  of  this  kind  is  especially  vivid 
when  occurring  in  an  afebrile  patient  to  whom  one  of  these  drugs  has 
been  administered.    The  fever  lasts  no  more  than  twenty-four  hours, 


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Fig.  31. — Malaria  complicating  phthisis. 

as  a  rule,  but  I  have  seen  cases  in  which  it  lasted  longer.  Hypodermic 
medication  is  more  apt  to  act  this  way,  and  Mantoux  says  that  injec- 
tions of  salt  solution  may  also  elevate  the  temperature. 

Diagnostic  and  Prognostic  Significance  of  Fever  in  Phthisis. — Sum- 
marizing the  results  obtained  in  this  section,  we  may  say  that  in  a  patient 
who  shows  a  distinct  elevation  of  temperature  during  the  afternoon 
for  several  weeks,  and  no  other  cause  can  be  found,  tuberculosis  is 
to  be  thought  of.  If  it  is  provoked  by  moderate  exercise,  and  persists 
after  more  than  an  hour  of  rest,  it  is  almost  pathognomonic  of  phthisis. 
If  with  it  there  are  other  symptoms,  such  as  nightsweats,  anemia,  loss 
of  weight,  cough,  emaciation,  etc.,  tuberculosis  is  in  all  probability 

1  Rev.  gen.  de  clin.  et  de  thSrap.,  1906,  xx,  639. 

2  Revue  de  la  tuberculose,  1907,  iv,  395. 


NIGHTSWEATS  183 

the  cause,  even  if  the  physical  signs  are  not  definite.  The  diagnosis 
is  more  certain  if  the  morning  temperature  is  subnormal. 

In  the  course  of  the  disease  a  high  temperature  during  the  day,  never 
touching  the  normal,  and  ascending  in  the  evening  is  an  indication  of 
progressive  activity  of  the  process  in  the  lung.  The  disease  is  progress- 
ing slowly,  or  is  even  quiescent,  when  the  temperature  in  the  early 
morning  on  rising  is  subnormal  or  normal  and  remains  so  during  the 
day,  not  rising  above  101°  F.  late  in  the  afternoon  or  evening. 

High,  continuous  temperature,  above  103°  F.,  is  an  indication  of 
extension  or  dissemination  of  the  disease  in  the  lung,  and  if  it  lasts 
for  more  than  a  month,  a  fatal  issue  is  to  be  expected;  even  if  some 
improvement  is  noted,  recovery  should  not  be  expected. 

Hectic  fever,  with  normal  or  subnormal  temperature  in  the  morn- 
ing and  high  fever,  103°  or  more  at  midday  or  later  is  an  ill  omen. 
While  the  patient  may  keep  on  in  this  condition  for  weeks  or  months, 
he  will  in  all  probability  never  leave  his  bed  alive. 

In  most  cases,  absence  of  fever  is  an  indication  of  an  improve- 
ment or  a  cure  of  the  disease,  but  there  are  many  exceptions,  and  the 
other  constitutional  symptoms  must  be  considered  when  formulating  a 
prognosis.  A  subnormal  temperature,  when  coming  on  suddenly, 
is  a  bad  sign.  When  chronic,  lasting  for  several  weeks,  however,  it 
is  not  incompatible  with  an  inactive,  though  not  necessarily  an 
inefficient,  life. 

NIGHTSWEATS. 

Nightsweats  have  at  all  times  been  considered  pathognomonic  of 
phthisis.  A  prolonged  cough  will  not  alarm  the  average  person,  but 
when  it  is  associated  with  nightsweats,  he  will  soon  consult  a  physician 
with  a  view  of  ascertaining  whether  or  not  he  is  tuberculous.  They 
are  met  with  quite  early  in  the  disease  in  many  cases;  at  times  when 
the  characteristic  symptoms  and  physical  signs  are  lacking,  but  in 
advanced  cases  their  severity  does  not  depend  altogether  on  the  extent 
of  the  lesion. 

Causes. — The  causes  of  nightsweats  are  obscure.  Some  have  attrib- 
uted this  phenomenon  to  the  compensatory  activity  of  the  skin 
when  the  pulmonary  respiratory  area  is  diminished,  but  we  meet  them 
in  cases  with  but  little  damage  to  the  lung.  Gustav  Heim^  is  of  the 
opinion  that  the  products  of  cell  disintegration,  and  especially  the 
toxins  produced  by  the  bacilli,  stimulate  the  sweat  centre  directly  or 
reflexly.  Just  as  after  childbirth  the  remains  of  the  placenta  may  pro- 
duce sweating.  It  is  an  attempt  on  the  part  of  the  body  to  rid  itself  of 
harmful  matter,  just  as  it  is  excreting  carbon  dioxide  in  the  sweat 
when  this  is  excessive  in  the  blood.  Smith  and  Brehmer  have  attrib- 
uted the  nightsweats  to  the  quick  change  of  the  tachycardia  of  the 
day  to  the  bradycardia  of  the  night.    Because  stimulating  food,  like 

1  Zeitschr.  f.  Tuberkulose,  1910,  xvi,  365. 


184  FEVER  AND  NIGHTSWEATS 

milk  piinclies,  often  prevent  nightsweats,  they  find  therein  a  con- 
firmation of  their  theory. 

It  appears  that  Cornet's  tlieory  is  more  in  harmony  witli  the  facts 
observed  cHnically.  He  looks  upon  nightsweats  as  due  to  the  absorp- 
tion of  the  proteins  of  the  tubercle  bacilli  and  other  microorganisms 
secondarily  implanted  in  phthisical  lesions.  The  toxins  are  absorbed 
into  the  blood  stream  and  they  stimulate  the  heat  centre,  thus  caus- 
ing fever;  and  also  act  upon  the  sweat  centre  in  the  cord  and  medulla 
and  the  peripheral  secretory  glands  and  thus  produce  perspiration.  He 
shows  that  this  also  confirms  the  fact  that  in  spite  of  the  great  dis- 
turbance the  diminished  excretion  of  fluid  and  the  greater  difficulty 
in  the  elimination  of  carbon  dioxide  which  is  characteristic  of  the 
chronic  course  of  the  disease  as  compared  with  acute  phthisis,  the 
secretion  of  sweat  is  incomparably  less  in  the  former,  owing  solely  to 
the  more  gradual  absorption  of  the  toxins. 

Symptomatology. — Nightsweats  usually  occur  in  the  second  part  of 
the  night,  about  2  to  4  a.m.,  in  typical  cases.  The  patient  retires 
with  some  fever,  and  in  hectic  cases  may  have  had  a  chill  on  the 
preceding  afternoon,  sleeps  rather  restlessly,  is  disturbed  by  dreams 
or  by  cough,  and  wakes  up  during  the  early  morning  hours  drenched 
with  perspiration.  At  times,  changing  the  night-  and  bedclothes  may 
prevent  their  recurrence  during  the  same  night,  but  in  many  cases 
this  is  of  no  avail,  as  the  sweats  again  trouble  the  unfortunate 
victim. 

In  the  milder  forms,  the  sweating  may  be  local,  on  the  forehead, 
the  neck,  the  chest,  etc.  Rarely  it  is  noted  on  only  one  side  of  the 
body,  usually  the  one  corresponding  to  the  pulmonary  lesion. 

In  the  progressive  and  hectic  cases  the  sweating  may  be  so  profuse 
and  drenching  as  to  exhaust  the  patient  who  often  begs  for  the  relief 
of  this  symptom  alone  which,  together  with  the  diarrhea,  is  instru- 
mental in  relieving  him  permanently  from  his  earthly  sufPerings. 

It  is  important  to  mention  that  the  nighsweats  do  not  directly  harm 
the  patient,  considering  that  only  1  per  cent,  of  solids  is  eliminated  in 
this  way,  of  which  0.7  per  cent,  is  salts,  mainly  uric  acid.  Only  so  far 
as  disturbing  sleep  is  concerned  are  nightsweats  harmful.  In  children 
their  diagnostic  significance  is  less  than  in  adults.  (See  Chapter  XXIV) . 

In  some  cases  the  disease  runs  its  course  without  any  or  only  with 
slight  nightsweats.  Kuthy  found  that  37  per  cent,  of  his  patients  had 
nightsweats  during  the  first  stage  of  the  disease.  In  the  third  stage, 
61.5  per  cent.  According  to  this  author,  women  are  more  apt  to  sweat 
profusely  than  men.  But  Louis  found  only  10  per  cent,  of  cases  with- 
out nightsweats,  and  at  the  Phipps  Institute  they  were  absent  in 41 
per  cent,  of  3344  cases. 

In  the  evolution  of  phthisis  it  is  observed  that  the  sweats  run  hand- 
in-hand  with  the  fever  and  the  general  condition  of  the  patient.  During 
afebrile  periods  they  are  absent,  to  return  with  an  acute  exacerbation. 
There  are  said  to  have  been  found  cases  of   nightsweats  without 


NIGHT  SWEATS  185 

fever,  but  my  experience  leads  me  to  believe  that  the  fever  is  over- 
looked in  such  cases.  One  of  the  best  signs  of  improvement  is  the 
complete  disappearance  of  the  nightsweats. 

Nightsweats  may  be  prevented  in  a  large  proportion  of  cases  by 
the  adoption  of  hygienic  bedding  and  coverings  during  sleep,  as  will 
be  shown  in  another  part  of  this  book. 

Sweating  appears  to  be  easily  provoked  in  the  phthisical.  Kuthy 
and  Wolff-Eisner  say  that  not  only  consumptives,  but  also  those 
"predisposed"  sweat  easily  and  when  waking  find  themselves  bathed 
more  or  less  in  perspiration.  Mild  exertion,  grief,  worry,  excitement, 
etc.,  may  be  followed  by  more  or  less  profuse  perspiration,  general  or 
local.  In  a  large  proportion  of  patients  we  see  sweating  in  the  armpits 
during  medical  examination,  even  in  patients  who  do  not  sweat 
during  the  night.  We  also  meet  with  patients  who  sweat  during  the 
day  while  taking  a  nap,  etc. 

While  most  authors,  notably  Cornet,  state  that  the  sweat  does  not 
carry  infection,  recent  investigations  by  Piery  have  shown  that  it  may 
contain  bacilli  which  are  pathogenic  to  animals.  Salters  showed  that 
hypodermic  injections  of  the  sweat  into  animals  act  like  tuberculin. 


CHAPTER  X. 
HEMOPTYSIS. 

Frequency. — To  the  layman  the  most  rehable  symptom  of  pul- 
monary tuberculosis  is  blood-spitting  and  many  physicians  share  this 
view,  although  we  know  that  a  large  proportion  of  cases  of  phthisis 
pursue  their  course  and  terminate  in  recovery,  or  fatally,  without 
any  hemoptysis,  while  in  many  patients  hemoptysis  is  not  due  to  tuber- 
culosis. The  statistics  of  the  frequency  of  this  symptom  vary  con- 
siderably, some  finding  it  in  but  25  per  cent.,  while  others  report  as 
many  as  80  per  cent,  having  had  hemorrhages  during  the  course  of 
phthisis.  Sokolowski  says  that  advanced  consumptives  who  did  not 
bleed  from  time  to  time  are  only  rarely  met  with.  Louis  found  this 
symptom  in  65  per  cent,  of  cases;  Walshe^  in  80  per  cent.;  Wilson 
Fox^  says  that  more  than  one-half  of  all  cases  of  phthisis  present  this 
symptom  in  some  part  of  their  course;  Williams  found  it  in  70  per  cent. ; 
Sorgo^  in  38  per  cent.,  Condie  in  only  24  per  cent.,  and  Elmer  H. 
Funk  in  54  per  cent. 

These  wide  differences  in  the  percentages  are  easily  explained 
by  the  fact  that  the  authors  have  not  taken  their  figures  from  com- 
parable material.  Some  have  spoken  only  of  fatal  cases,  other  of  cases 
in  their  private  practice,  while  still  others  have  taken  hospital  records 
as  their  criteria.  In  the  latter  classes  the  patients  were  observed  only 
for  a  short  time,  and  hemorrhages  which  may  have  taken  place  later 
have  not  been  considered. 

i^nders^  found  in  a  series  of  5302  cases  that  36.6  per  cent,  had  hemop- 
tysis. He  emphasizes,  however;  that  not  all  were  followed  until  the 
death  or  recovery  of  the  patients,  but  many  were  discharged  during 
the  course  of  the  affection.  In  fact,  among  289  cases  in  private  practice, 
kept  under  observation  for  a  longer  time,  as  a  rule,  hemoptysis  occurred 
in  41.8  per  cent.,  but  it  is  to  be  recollected  that  even  these  patients 
were  under  observation  for  less  than  half  of  their  duration.  Hemor- 
rhage is  more  apt  to  occur  in  advanced  cases,  and  those  who  base  their 
calculations  on  early  cases  in  sanatoriums  are  likely  to  find  low  per- 
centages, while  when  only  fatal  cases  are  taken  the  percentages  will 
be  too  high. 

Initial  Hemoptysis. — Of  great  interest  is  hemoptysis  as  an  initial 
symptom  of  phthisis.  But  statistics  on  this  subject  are  also  at  variance, 
because  we  meet  with  many  patients  who  have  been  coughing  and 

J  British  and  Foreign  Med.  Chir.  Re-^aew,  1849. 

-  Dis.  of  the  Lungs  and  Pleura,  London,  1S91,  p.  7.S5. 

3  Brauer,  .Schrodec,  and  Bhimenfeld's  Handbuch  d.  Tul)crkuh)so,  ii,  250. 

4  .Jour.  Amer.  Med.  Assn.,  1907,  xlix,  1067;   1909,  liii,  45,5. 


PATHOLOGY  187 

presented  other  symptoms  of  tuberculosis  for  months,  or  even  years, 
and  paid  little  attention  to  them  till  a  hemorrhage  brought  them  to 
their  senses.  Here  it  would  not  be  correct  to  consider  the  hemoptysis 
as  the  first  symptom. 

In  a  study  of  1932  cases  Reiche^  found  that  9.2  per  cent,  had  more 
or  less  profuse  hemorrhage  at  the  beginning  of  the  disease,  and  in 
one-fourth  of  these  it  was  rather  copious.  He  finds  that  those  who 
bleed  at  the  beginning  are  more  apt  to  bleed  during  the  course  of  the 
disease  than  those  who  do  not;  the  ratio  is  57.9  per  cent,  and  31.7 
per  cent.  Sorgo  found  during  a  period  of  observation  extending  over 
ten  years  that  12.9  per  cent,  of  5872  patients  had  initial  hemorrhages. 
Kuthy^  reports  that  while  54.3  per  cent,  of  his  patients  had  hemoptysis, 
only  two-fifths  of  these  (22.3  per  cent.)  were  initial  hemorrhages. 
Anders  arrives  at  the  conclusion  that  in  about  10  per  cent,  of  cases 
of  phthisis,  hemoptysis  first  directed  attention  to,  and  is  almost  in- 
variably followed  by,  demonstrable  and  conclusive  evidence  of  the 
disease;  but  in  not  less  than  25  per  cent,  of  all  cases  of  chronic  pul- 
monary tuberculosis,  hemoptysis  is  among  the  ushering-in  symptoms 
of  the  active  recognizable  period  of  the  affection. 

Pathology. — The  diagnostic  and  prognostic  significance  of  hemop- 
tysis can  only  be  appreciated  when  we  have  a  clear  understanding 
of  the  anatomical  changes  responsible  for  the  bleeding.  There  are 
several  varieties  of  pulmonary  lesions  which  may  bring  about  ex- 
udation of  blood  from  the  lung  tissues :  Local  inflammatory  or  active 
hyperemia;  ulceration  of  a  bloodvessel,  and  aneurismal  dilation  of 
bloodvessels  are  the  most  important  in  phthisis. 

The  initial  hemoptyses  are  .said  to  be  caused  merely  by  localized, 
active  inflammatory  hyperemia.  In  other  words,  they  are  of  the 
same  origin  as  the  rusty  sputum  of  pneumonia.  But  we  may  well 
understand  that  this  bleeding,  caused  by  diapedesis,  cannot  be  profuse 
— only  blood-streaked  sputum  may  thus  be  brought  about.  This  is 
met  with  in  all  stages  of  phthisis  and  can  only  be  accounted  for  in  this 
manner.  On  the  other  hand,  blood-streaked  sputum  does  not  in- 
variably mean  that  it  is  caused  by  localized  hyperemia  and  that  the 
lesion  is  not  serious,  because  not  all  the  extravasated  blood  is  brought 
out  through  the  mouth.  Quite  some  of  it  remains  in  the  lungs  and 
bronchi,  and  is  more  or  less  quickly  absorbed,  as  was  shown  by 
Nothnagel.  When  the  hemorrhage  is  not  profuse  we  must  not  con- 
clude that  the  case  is  mild  or  that  the  lesion  is  not  extensive. 

When  the  pulmonary  lesion  proceeds  from  infiltration  to  caseation, 
then  to  softening  and  finally  to  liquefaction,  it  undoubtedly  implicates 
the  bloodvessels  that  pass  through  it  and  produces  the  same  changes 
in  the  lung  tissue  which  surrounds  it.  It  is  therefore  strange  at  first 
sight  that,  considering  the  ulcerative  processes  and  the  destruction 
of  tissue,  hemorrhages  do  not  occur  more  often.    But  this  is  explained 

'  Zeitschr.  f.  Tuberkulose,  1902,  iii,  22.3. 

2  Die  Prognosenstellung  bei  der  Lungentuberkulose,  p.  299. 


188  HEMOPTYSIS 

by  the  strong  tendency  to  the  formation  of  throm])i  in  the  l^lood- 
vessels,  excepting  in  very  acute  cases.  In  chronic  cases  there  usually 
occurs  a  narrowing  or  complete  obliteration  of  the  vessel  by  the  growing 
tubercles  which,  when  finally  ulcerating,  may  leave  an  erosion  through 
which  the  blood  can  flow  more  or  less  freely  till  it  is  occluded  by  a 
thrombus.  INIoreover,  the  increased  blood-pressure  at  the  infected 
and  inflamed  area  dflates  the  softened  vessels  and  causes  small, 
aneurisms  which  have  been  described  elsewhere.  This  is  clear  when 
we  bear  in  mind  that  the  bloodvessels  in  the  lungs  are  terminal  branches 
of  the  pulmonary  artery.  These  aneurisms  may  easily  rupture  and 
permit  blood  to  escape. 

Most  cases  of  hemoptysis  end  in  recovery,  and  the  pathological 
changes  in  the  lung  at  the  time  of  the  bleeding  can  only  be  surmised, 
but  in  fatal  hemorrhages  we  often  have  an  opportunity  to  observe  the 
anatomical  changes.  Here  we  usually  find  that  the  source  of  the 
bleeding  was  an  exposed  vessel,  left  bare  after  the  surrounding  pul- 
monary tissue  had  softened  and  was  eliminated.  The  loss  of  support, 
as  well  as  the  pathological  changes  in  the  perivascular  tissues,  and  the 
erosions  of  the  tunicte  adventitia  and  media  lead  to  aneurismal  dflata- 
tions  of  the  inner  coat  which  give  way  to  the  pressure  exerted  on  them 
by  the  circulating  blood. 

The  rupture  of  these  aneurisms  at  times  strikes  down  a  patient 
who  is  on  the  road  to  recovery  when  a  hemorrhage  occurs  like  a 
storm  ou,t  of  a  clear  sky.  When  the  cavity  into  which  the  aneurism 
or  the  lacerated  artery  opens  is  small,  the  extra vasated  blood  usually 
coagulates  and  the  clot  obstructs  the  opening  of  the  bloodvessel, 
thus  stopping  the  bleeding.  But  in  large  cavities,  or  when  the  blood 
is  deficient  in  coagulability,  which  is  not  rare,  the  bleeding  keeps  on 
till  the  patient  dies  of  acute  anemia.  I  have  seen  at  autopsy  a  large 
cavity  filled  with  about  a  quart  of  blood  which  killed  a  patient  during 
the  night.  After  clearing  out  the  clots  we  found  an  eroded  artery 
about  2  mm.  in  diameter,  and  passing  a  probe  through  it,  we  found 
it  only  about  6  cm.  from  the  pulmonary  artery.  This  patient  had 
such  a  sharp  hemorrhage  that  he  was  unable  to  call  for  assistance. 

In  more  acute  cases  of  phthisis,  in  which  the  destruction  of  lung 
tissue  is  going  on  at  a  rapid  pace,  the  hemorrhages  usually  come 
from  ulcerating  erosions  of  large  pulmonary  vessels  and  may  prove 
fatal  immediately.  Here  there  is  no  time  for  narrowing  of  the  blood- 
vessel, thus  preparing  it  that  in  case  of  rupture  it  may  be  easily  re- 
paired by  occlusion  with  a  thrombus  which  saves  the  majority  of 
chronic  consumptives  from  death  due  to  this  cause.  In  acute  pneu- 
monic phthisis  which  very  often  begins  with  sharp  and  profuse  hemor- 
rhage, I  have  usually  been  able  to  find  signs  of  cavitation  when  the 
acute  process  subsided  and  the  disease  pursued  a  chronic  or  subacute 
course.  This  confirms  the  view  that  profuse  hemorrhage  is  not  caused 
by  mere  active  inflammatory  hyperemia,  but  by  actual  erosion  of  a 
bloodvessel. 


HEMOPTYSIS  AT  THE  ONSET  OF  PHTHISIS  189 

In  fibroid  phthisis  the  sources  of  hemorrhages  are  lacerated,  dilated 
or  varicose  bloodvessels  which  pass  through  bronchiectatic  cavities, 
characteristic  of  this  form  of  the  disease  and  also  oozing  from  capillaries 
or  arteries  which  traverse  the  granulations  on  the  walls  of  the  cavities. 
The  bleeding  is  therefore  not  profuse,  as  a  rule,  in  these  cases,  but  it 
is  recurring  in  many  cases. 

Hemoptysis  at  the  Onset  of  Phthisis. — As  the  first  symptom  to  draw 
the  attention  of  the  patient  to  his  affection,  hemoptysis  occurs  in  two 
different  types.  We  meet  it  in  patients  who  have  felt  perfectly  well 
till  the  instant  the  hemorrhage  made  its  appearance  without  any 
premonitory  symptoms.  Even  close  questioning  does  not  elicit 
any  symptoms  preceding  the  bleeding.  While  at  work,  or  engaged 
in  an  animated  conversation,  or  even  waking  up  from  sleep  during  the 
night,  the  patient  feels  a  sensation  of  warmth  in  the  throat,  coughs 
and  expectorates  a  mouthful  of  blood;  or  during  a  fit  of  coughing 
he  brings  up  some  blood-streaked  sputum.  A  careful  examination 
of  the  chest  and  skiagraphy  may  fail  to  disclose  anything  conclusive 
of  pulmonary  disease.  The  temperature  is  and  remains  normal,  the 
appetite  is  good,  but  for  a  few  hours  or  days  the  patient  continues 
to  bring  up  dark  clots,  and  when  this  ceases  he  is  apparently  none  the 
worse  for  his  experience.  "  Many  of  these  patients  subsequently  pass 
through  life  without  experiencing  anything  that  may  lead  to  the 
suspicion  of  tuberculosis.  This  is  seen  in  many  who  have  passed 
through  an  attack  of  abortive  tuberculosis,  details  of  which  are  given 
later  on.  Some  patients  give  a  history  of  such  a  hemorrhage  many 
years  before  the  onset  of  active  phthisis. 

In  many  others  the  initial  hemorrhage  continues  for  several  days 
and  when  it  finally  ceases  the  patient  shows  symptoms  of  phthisis — 
cough,  expectoration,  tachycardia,  nightsweats,  etc.  Physical  explora- 
tion of  the  chest  reveals  distinct  signs  of  a  lesion  in  one  or  both 
apices  and  tubercle  bacilli  may  be  found  in  the  sputum.  The  subse- 
quent course  of  the  disease  is  that  of  chronic  phthisis,  though  a  large 
proportion  of  cases  are  aborted  within  a  few  months,  and  I  have  met 
with  patients  who  have  had  several  attacks  of  hemoptysis  at  long 
intervals,  have  shown  some  indefinite  or  even  conclusive  apical  signs, 
and  rarely  tubercle  bacilli  in  the  sputum,  yet  they  remained  well 
indefinitely. 

A  different  clinical  type  of  hemoptysis  is  seen  in  patients  who 
maintain  that  they  have  felt  quite  well,  but  close  questioning  reveals 
the  fact  that  they  have  been  coughing  for  months,  bringing  up  muco- 
purulent sputum ;  that  the  appetite  has  failed  and  that  they  have  lost 
weight  and  strength.  In  women  we  may  find  that  they  have  missed 
one  or  more  of  their  periods.  They,  however,  considered  these  symp- 
toms trifling  and  continued  at  their  work,  or  consulting  a  physician, 
they  were  told  that  it  was  only  a  slight  "cold." 

The  hemoptysis  in  these  cases  is  apt  to  be  profuse  and  last  for  several 
days  because,  while  insidious  in  its  arrival,  the  tuberculous  process 


190  HEMOPTYSIS 

in  the  lungs  has  usually  progressed  quite  far;  indeed  I  have  met  with 
signs  of  pulmonary  excavations  in  such  "initial"  hemorrhages.  In 
the  majority  of  cases  physical  exploration  of  the  chest  reveals  a  lesion 
of  moderate  extent,  though  on  rare  occasions  we  find  nothing  definite, 
even  with  the  aid  of  skiagraphy.  But  the  cough,  fever,  nightsweats, 
expectoration,  etc.,  continue  and  the  diagnosis  is  made  without  con- 
clusive physical  signs.  In  most  cases  tubercle  bacilli  are  found  in  the 
sputum.  It  is  the  prolonged  and  slow  convalescence  after  the  attack 
of  hemoptysis  that  distinguishes  these  cases  from  the  initial  hemor- 
rhages of  abortive  tuberculosis. 

Hemorrhages  during  the  Advanced  Stages. — In  confirmed  chronic 
cases  of  phthisis  we  may  meet  with  hemoptysis  at  any  period  of  the 
disease,  though  it  may  be  added  that  it  is  most  frequent  in  the  early 
and  very  late  stages.  The  bleeding  may  be  of  various  degrees,  from 
that  of  sputum  tinged  with  blood  to  the  expectoration  of  several 
mouthfuls  of  pure,  bright  red  blood,  to  a  copious  hemorrhage  during 
which  several  pints  are  brought  up  within  twenty-four  hours,  and  in 
rare  cases  it  has  been  reported  that  as  much  as  three  quarts  of  blood 
were  brought  up. 

The  blood  is  bright  red,  frothy,  usually  mixed  with  sputum.  When 
bleeding  is  very  profuse  the  blood  may  be  "blue"  or  venous.  It  is 
evident  that  in  most  cases  the  blood  does  not  coagulate  quickly — 
some  clots  are  seen,  but  the  bulk  remains  fluid;  even  the  addition  of 
calcium  salts,  serum  and  tissue  extracts  does  not  enhance  its  coag- 
ulability. E.  Magnus  Alsleben^  has  added  normal  blood  without 
increasing  its  power  of  coagulation.  The  reasons  for  this  delayed 
coagulability  are  not  clear. 

Many  patients  have  some  premonitory  warning  before  the  onset  of 
hemoptysis,  and  I  have  had  one  who  could  foretell  bleeding  twenty- 
four  hours  in  advance.  At  times  there  is  a  rise  in  temperature,  and 
pains  in  the  chest  are  aggravated,  or  the  cough  becomes  more  annoying. 
But  in  most  patients  the  onset  is  sudden  and  unexpected.  The  patient 
has  a  sensation  of  gurgling  or  tightness  in  the  chest,  followed  by  a 
fit  of  cough  productive  of  bright  red,  frothy  blood  which  has  a  salty 
taste  and  partly  coagulates  in  the  vessel  into  which  it  is  deposited, 
forming  flattened  lumps.  When  very  profuse,  which  is  comparatively 
rare,  the  patient  is  overwhelmed  and  can  hardly  cough — the  blood- 
gushes  in  an  almost  steady  stream  through  the  mouth  and  at  times 
through  the  nose. 

The  general  appearance  of  the  average  patient  is  that  of  shock- 
he  is  prostrated,  often  out  of  proportion  to  the  amount  of  blood  lost; 
his  countenance  is  that  of  a  frightened  individual,  unnerved,  anxious 
and  terrified;  the  face  pale,  the  extremities  cold  and  clammy.  The 
temperature,  which  may  have  been  above  normal  before  the  onset  of 
the  bleeding,  suddenly  sinks,  often  to  a  subnormal  degree,  the  pulse 
is  rapid,  soft  and  small. 

1  Zeitschr.  f.  kliu.  Med.,  l'J14,  Ixxxi,  9. 


HEMORRHAGES  IN  FIBROID  PHTHISIS  191 

That  these  symptoms  of  collapse  are  not  due  wholly  to  the  loss  of 
blood  is  evident  from  the  fact  that  the  family  is  also  panic  striken, 
and  some  are  in  the  same  state  of  collapse  as  the  patient,  showing 
the  profound  influence  this  symptom  has  on  the  average  person. 

After  getting  some  reassuring  encouragement  from  his  physician 
there  is  usually  observed  a  reaction  in  the  patient — the  pulse  improves, 
the  face  becomes  flushed  and  the  temperature  rises  to  the  same  degree 
as  it  was  before  the  onset  of  the  bleeding,  or  higher.  In  many  cases 
there  is  soon  a  relapse,  the  bleeding  is  repeated  within  a  few  hours 
or  the  next  day  and  it  may  keep  on  at  irregular  intervals  for  a  week 
or  more.  When  it  finally  stops  the  patient  continues  to  expectorate 
dark  blood-clots  with  his  sputum  for  several  days.  In  some  cases 
the  bleeding  continued  for  weeks,  letting  up  for  a  day  or  two  to  reap- 
pear; rarely  until  the  patient  expires  from  exsanguination,  cerebral 
anemia,  and  cardiac  asthenia. 

In  cases  with  large  pulmonary  cavities  the  bleeding  may  be  very 
copious.  The  quantity  of  blood  brought  out  is  not  all  that  has  escaped 
from  the  bleeding  vessel.  A  considerable  part  is  swallowed  automatic- 
ally, and  some  remains  in  the  cavities  or  the  bronchi  and  is  subsequently 
absorbed.  The  outcome  of  the  bleeding  depends  on  the  size  of  the 
cavity  and  the  coagulability  of  the  blood.  In  rare  cases  the  weak 
and  emaciated  patient  is  overwhelmed  by  the  bleeding  and  is  unable 
to  expel  it  from  the  lungs,  expiring  in  a  few  minutes,  drowned  or  suffo- 
cated by  his  own  blood.  Other  patients  make  a  vain  fight  for  hours 
or  days  but  finally  succumb  to  exanguination.  But  the  chances  of 
recovery  of  a  bleeding  patient  with  a  cavity  in  the  lung  are,  on  the 
whole,  not  bad.  Aii  immediate  fatal  issue  is,  after  all,  exceptional; 
less  than  2  per  cent,  of  consumptives  die  from  hemorrhage  directly. 
The  vast  majority  of  hemorrhages  are  well  borne,  the  patient  dying, 
if  at  all,  from  other  symptoms  or  complications. 

On  the  other  hand,  we  meet  with  patients  who  have  made  an  excellent 
recovery,  but  suddenly  profuse  hemorrhages  occur  which  carry  them 
off  within  a  few  hours  or  days.  I  was  once  called  to  attend  a  patient 
who  was  discharged  from  a  sanatorium  three  days  previously  as  an 
arrested  case  of  phthisis.  He  succumbed  to  the  bleeding.  These 
hemorrhages  are  fortunately  rare  and  are  usually  due  to  the  rupture 
of  an  aneurism  in  a  dried  and  contracted  cavity.  They  can  neither 
be  foreseen  nor  prevented. 

Hemorrhages  in  Fibroid  Phthisis. — In  this  form  of  phthisis  hemop- 
tysis is  very  frequent.  In  most  cases  it  is  very  slight,  only  blood- 
tinged  sputum  being  brought  up.  They  may  feel  quite  well  in  general, 
excepting  for  the  dyspnea  and  the  cough  to  which  they  have  adapted 
themselves.  But  no  sooner  does  blood  make  its  appearance  in  the 
sputum  than  they  are  alarmed.  I  have,  however,  had  some  patients 
who  did  not  mind  the  blood-tinged  sputum  much,  knowing  from 
experience  that  it  is  not  at  all  dangerous. 


192  HEMOPTYSIS 

Hemorrhagic  Phthisis. — There  is  a  form  of  phthisis  which  is  char- 
acterized by  frequent  and  recurrent  hemorrhages,  the  hemorrhagic 
phthisis  of  the  old  writers.  The  bleeding  occurs  at  irregular  intervals 
for  years  without  harming  the  patient  very  much.  In  these  patients 
we  may  not  jQnd  any  definite  physical  signs  in  the  chest,  no  fever, 
no  pronounced  emaciation,  and  but  little  cough.  Only  the  hemoptysis 
and,  at  times,  the  bacilli  in  the  sputum  reveal  the  condition.  I  have 
had  under  my  care  at  the  Montefiore  Home  a  woman  in  whom  neither 
any  of  the  other  physicians  nor  myself  were  quick  in  making  a  diagnosis 
of  tuberculosis  from  the  indefinite  physical  signs  and  the  skiagram 
of  the  chest.  In  fact,  we  had  suspected  malingering  and  emploj'ed 
strong  measures  to  make  sure  that  the  temperature  readings  were 
not  influenced  by  manipulations  of  the  thermometer,  and  that  the 
sputum  was  expectorated  by  the  patient,  suspecting  that  there  was 
some  deception  on  the  part  of  the  patient,  who  liked  to  remain  in  the 
hospital.  Even  during  the  more  or  less  copious  attacks  of  hemorrhage 
which  recurred  at  frequent  but  irregular  intervals  and  often  lasted 
for  several  weeks,  no  conclusive  physical  signs  could  be  elicited  in  the 
chest.  I  have  another  patient  who  has  bled  at  least  twice  a  year  for 
the  past  fifteen  years  and  feels  quite  well.  Andral  mentions  a  case 
which  bled  off  and  on  for  sixty  years  and  finally  succumbed  at  the  age 
of  eighty  to  some  disease  of  the  chest.  •  These  cases  are  uncommon 
but  we  meet  them  now  and  then.  In  some  we  find  signs  of  more 
or  less  extensive  pulmonary  lesions  which  remain  stationary  or  quies- 
cent in  spite  of  the  recurring  hemorrhages.  The  lesion  is  benign 
notwithstanding  the  tubercle  bacilli  which  are  found  in  the  sputum, 
and  at  times,  though  rarely,  there  may  be  one  hemorrhage  which 
proves  fatal.  It  has  been  stated  that  in  most  of  these  cases  the  lesion 
is  localized  in  the  tracheobronchial  glands. 

Exciting  Causes  of  Hemoptysis. — ^We  have  seen  that  while  hemop- 
tysis is  rather  co  mmon  among  consumptives,  still  many  pass  through 
the  disease  till  the  end,  recovery  or  death,  without  this  accident.  There 
appears  to  be  some  evidence  showing  that  tall  persons  are  more  likely 
to  bleed  than  those  of  shorter  stature,  and  Wolff  states  that  for  this 
reason  women  show  a  lesser  proportion  of  bleeders  than  men.  Strand- 
gaard^  suggests  that  the  tall  patients  are  more  likely  to  bleed  because 
they  have  larger  hearts  and  higher  blood-pressure,  but  this  view  has 
not  been  confirmed.  While  hemoptysis  has  been  seen  at  all  ages, 
even  in  infants,  still  most  of  the  cases  occur  between  fifteen  and  fifty, 
probably  because  at  this  period  most  of  the  cases  of  phthisis  are 
active. 

From  Ander's  statistics  it  appears  that  males  are  more  liable  to 
hemoptysis  than  females  and  prior  to  the  twentieth  year  of  age  there 
is  a  slight  preponderance  in  favor  of  the  female  sex.  In  Thompson's^ 
collective  investigation  the  women  showed  greater  liability  than  the 

1  Zcitschr.  f.  Tuberkulose,  1908,  xii,  209. 

*  Causes  and  Results  of  Pulmonarj^  Hemorrhage,  Loudon,  1879. 


EXCITING  CAUSES  OF  HEMOPTYSIS  193 

men.  But  Anders  shows  that  this  increased  incidence  in  the  female 
sex  is  confined  principally  to  the  first  two  decades  of  life.  After  the 
thirtieth  year  the  number  of  males  preponderates.  Females  are  also 
less  liable  to  suffer  from  copious  and  fatal  hemorrhages.  My  own 
experience  coincides  with  that  of  Anders,  that  an  immediately  fatal 
hemorrhage  is  relatively  rare  in  women.  Initial  hemoptysis  is  also 
less  frequent  in  women  than  in  men.  Reiche's  statistics  show  that  it 
occurred  in  11  per  cent,  of  the  latter  as  against  only  5.5  per  cent,  in 
the  former;  Sorgo  found  the  ratio  as  11  and  13.5  per  cent,  respectively; 
while  Berthold  Miiller^  found  it  in  equal  proportion  in  both  sexes. 

Patients  with  a  nervous  and  excitable  temperament  are  more  apt 
to  suffer  from  this  complication  than  the  indolent  and  phlegmatic. 
During  some  animated  conversation,  overexertion,  singing,  running, 
mountain  climbing,  straining  at  stool,  or  as  a  result  of  traumatism, 
hemorrhage  may  be  provoked.  It  is  also  a  fact  worthy  of  the  careful 
attention  of  clinicians  that  consumptives  who  have  been  urged  on 
to  eat  excessively,  becoming  plethoric,  ruddy  and  fat,  bleed  more 
often  than  those  who  eat  well,  but  moderately.  Exposure  to  the 
inclemencies  of  the  weather  may  excite  hemoptysis,  probably  by 
causing  an  acute  localized  pneumonic  process  at  the  site  of  the  tuber- 
culous lesion.  Coitus  may  excite  it  and  I  have  known  two  cases  of 
fatal  hemorrhage  which  occurred  soon  after  intercourse. 

Certain  drugs  used  extensively  in  phthisiotherapy,  as  arsenic, 
creosote  and  its  derivatives,  the  iodides,  aspirin,  etc.,  are  often  in- 
strumental in  bringing  on  hemoptysis.  It  has  been  stated  that  resi- 
dence in  high  altitudes  favors  hemoptysis,  but  it  has  not  been  proved ; 
as  will  be  shown  elsewhere,  the  prognosis  of  hemorrhage  is  worse 
in  these  regions  than  at  sea  level. 

Some  authors  have  found  that  there  are  seasonal  influences  in  the 
production  of  hemoptysis,  saying  that  the  spring  and  summer  months 
give  the  highest  incidence,  while  Anders's  collective  investigations 
show  that  it  is  most  prevalent  in  the  months  of  December,  January, 
and  February;  August,  September,  May  and  March,  in  the  order 
named,  seem  to  rank  next.  The  experience  at  the  Phipps  Institute 
coincides  with  those  of  Anders.  Burns^  says  that  "  barmometer  changes 
seem  to  have  little  effect  on  the  symptomatology.  In  a  few  instances 
hemorrhages  have  occurred  following  a  fall  in  the  barometer  but  in 
insufficient  number  of  cases  to  justify  constant  relation.  It  is  probably 
a  matter  of  coincidence  only  so  far  as  the  barometer  alone  is  concerned. 
There  is  a  larger  number  of  patients  streaking  in  March,  May  and 
especially  June  than  in  other  months.  Hemorrhage  occurred  more 
frequently  in  June  than  in  any  other  month." 

I  have  observed  in  my  hospital  work  that  hemorrhages  often  occur 
in  epidemic  form,  a  large  number  of  patients  bleed  at  the  same  time 
in  a  ward.     This  may  be  explained  by  some  intercurrent  infection, 

1  Zeitschr.  f.  Tuberkulose,  1910,  xiii,  133. 
-  Boston  Med.  and  Surg.  Jour.,  1914,  clxx,  564. 
13 


194  HEMOPTYSIS 

especially  influenza,  causing  pulmonary  congestion.  But  psychic 
influences  may  also  be  at  work. 

Any  of  the  above-mentioned  factors  may  be  the  apparent  exciting 
cause,  but  this  is  not  true  of  the  majority  of  cases.  In  my  experience, 
a  large  proportion  of  hemorrhages,  especially  copious  ones,  begin  when 
the  patients  have  the  least  reason  to  expect  them.  It  is  the  universal 
experience  in  sanatoriums  that  patients  who  have  been  kept  under 
a  rigorous  rest  cure  may  bleed.  Furthermore,-  about  one-half  the 
hemorrhages  begin  during  the  night  when  the  patient  is  resting  in  bed 
or  sleeping,  and  suddenly  wakes  up  with  a  cough,  followed  by  a  mouth- 
ful of  blood.  In  patients  with  eroded  bloodvessels  or  miliary  aneurisms 
in  the  lungs,  bleeding  is  apt  to  occur  without  any  known  provocative 
cause,  and  usually  it  cannot  be  prevented  by  any  known  means. 

Diagnostic  Significance  of  Hemoptysis. — It  has  been  repeatedly 
stated  that  all  cases  of  hemoptysis  should  be  considered  of  tuberculous 
origin  and  treated  accordingly  until  proved  to  be  due  to  some  other 
cause.  But  just  because  the  vast  majority  of  hemoptyses  are  due  to 
tuberculosis  of  the  lungs,  when  the  blood  is  derived  from  some  other 
source,  it  at  times  proves  a  serious  source  of  error.  I  have  seen  hema- 
temesis  treated  as  hemoptysis  on  several  occasions.  Though  this 
could  be  easily  avoided  by  carefully  noting  the  manner  in  which  the 
blood  is  brought  out,  yet  I  have  seen  two  cases  in  which  this  was  not  so 
simple  and  an  immediate  diagnosis  could  not  be  made. 

The  most  perplexing  cases  that  present  themselves  in  physicians', 
offices  are  patients  who  claim  that  several  days  ago  they  expecto- 
rated blood.  In  many  the  blood  was  derived  from  the  nose,  throat, 
gums,  etc.  Examination  of  these  parts  may  not  reveal  any  irritation, 
hyperemia  or  varices,  while  in  the  chest  there  are  found  some  indefinite 
signs  of  an  apical  lesion  which  may  be  of  non-tuberculous  origin, 
thus  leading  to  an  erroneous  diagnosis  of  tuberculosis.  This  is  espe- 
cially seen  in  cases  of  epistaxis  in  which  the  blood  trickled  down  the 
posterior  nares,  exciting  cough  productive  of  blood  or  blood-streaked 
sputum.  Some  patients  have  epistaxis  during  the  night,  wake  up 
spitting  blood  and  present  themselves  promptly  in  the  morning  for 
a  medical  examination  which  does  not  reveal  any  definite  clues  as  to 
the  source  of  the  bleeding. 

Streaky  Sputum. — Great  care  must  be  exercised  before  diagnosing 
tuberculosis  based  on  a  history  of  blood-streaked  sputum.  While 
this,  when  originating  in  the  lungs,  may  be  a  precursor  of  a  large  and 
profuse  hemorrhage,  it  is,  however,  a  fact  that  streaky  sputum  only 
rarely  originates  in  the  pulmonary  parenchyma;  the  vast  majority 
comes  from  the  nose,  throat  and  esjjecially  the  })ronchi.  West^  says 
that  streaky  hemoptysis  is  far  more  frequent  in  i)ronchitis  than  in 
phthisis.  When  it  occurs  in  phthisis  it  is  generally  due  to  the  same 
cause,  viz.,  the  rupture  of  distended  capillaries  in  the  bronchial  tubes 

*  Diseases  of  the  Organs  of  Respiration,  London,  1909,  ii,  381. 


DIAGNOSTIC  SIGNIFICANCE  OF  HEMOPTYSIS  195 

as  the  result  of  violent  coughing;  but  when  the  tubes  are  the  seat  of 
tubercular  ulceration,  bleeding  may  sometimes  take  place  from  the 
ulcerated  surface,  usually  in  small  amount  and  streaky,  but  occasion- 
ally in  larger  amount. 

In  many  cases  with  a  history  of  streaky  sputum  the  diagnosis  can 
only  be  cleared  up  by  careful  observation  for  weeks,  after  the  presence 
or  absence  of  fever,  tachycardia,  anorexia  and  physical  signs  in  the 
chest  are  carefully  studied.  Very  often  the  blood  is  derived  from 
congestion  in  chronic  pharyngitis  with  a  spongy  mucous  membrane, 
or  from  dilated  or  varicose  bloodvessels  in  the  trachea  or  main  bronchi 
common  in  asthma  and  chronic  bronchitis.  Varicosities  of  the 
esophagus  are  also  said  to  be  quite  common.  Recently  Gorel  and 
Gignoux^  have  described  fausses  hemo'ptyses  due  to  varices  at  the 
base  of  the  tongue  which  are  visible  in  the  laryngeal  mirror.  The 
vein  may  be  large  and  dilated  and  often  extends  to  the  fold  of  the 
epiglottis,  or  only  a  number  of  blue  or  dark  blue  specks  may  be  noted, 
at  times  confluent,  greatly  resembling  a  vascular  tumor.  .These  are 
very  often  causes  of  hemoptysis.  They  are  found  mostly  in  persons 
between  forty  and  fifty  years  of  age,  especially  those  who  show  other 
stigmata  of  arteriosclerosis  and  other  varicosities,  as  on  the  legs,  or 
hemorrhoids. 

These  false  hemoptyses  have  been  described  by  many  English 
physicians.  Williams^  speaks  of  persons  who,  without  any  symptoms 
of  lung  disease,  bring  up  quantities  of  blood  and  recover  without 
permanent  cough.  He  says  that  they  were  generally  middle-aged 
and  often  had  the  arcus  senilis.  Recovery  is  the  rule.  Sir  Andrew 
Clark^  also  describes  "arthritic  hemoptysis"  occurring  in  elderly 
persons  free  from  ordinary  disease  of  the  heart  and  lungs;  a  form  of 
hemoptysis  arising  out  of  minute  structural  alterations  in  the  terminal 
bloodvessels  of  the  lung.  These  vascular  changes  occur  in  persons  of 
the  arthritic  diathesis,  resemble  the  vascular  alterations  found  in 
osteo-arthritic  articulations,  and  are  themselves  of  an  arthritic  nature. 
More  recently  F.  de  Havilland  Hall*  attributed  these  hemorrhages 
to  high  vascular  tension.  Even  though  it  occurs  in  a  patient  who 
has  had  phthisis,  this  form  of  hemoptysis  is  not  necessarily  due  to  a 
recrudescence  of  the  disease,  but  may  be  the  result  of  high  tension 
with  degenerate  vessels. 

Hemoptysis  in  Heart  Disease. — Blood-spitting  in  heart  disease  is 
often  treated  as  of  tuberculous  origin  with  disastrous  results.  In- 
asmuch as  we  very  often  meet  with  cardiacs  who  are  emaciated,  cough 
and  have  occasionally  mild  pyrexia,  the  diagnosis  of  tuberculosis  is 
at  times  made  erroneously.  It  is  in  fact  usually  supported  by  some 
physical  signs  in  the  chest,  because  cardiacs  may  show  defective 

1  Lyon  MM.,  1911,  xliii,  191.3. 

2  Pulmonary  Consumption,  London,  1887,  p.  135. 

3  Trans.  Med.  Society  of  London,  1889,  xii,  9;    Lancet,  1889,  ii,  840. 
*  Lancet,  1915,  ii,  329. 


196  HEMOPTYSIS 

resonance,  alteration  in  breath-sounds  and  even  rales  over  an  apex, 
or  other  parts  of  the  chest  as  a  result  of  infarction,  peripheral  throm- 
bosis, or  brown  induration.  I  have  seen  cases  of  organic  heart  disease 
treated  in  tuberculosis  clinics  and  day  camps  in  New  York  City  for 
months.  In  infarction  the  expectorated  blood  may  be  bright  red, 
but  in  mitral  disease  small,  solid,  purple  or  black  lumps  which  sink  in 
water  are  usually  brought  up.  They  are  derived  from  ruptured 
capillaries  in  the  walls  of  air  cells  where  they  remain  for  some  time 
before  they  are  expectorated.  The  experienced  eye  can  generally 
distinguish  them. 

According  to  Frederick  W.  Price,^  mitral  stenosis  is  probably  the 
next  most  frequent  cause  of  hemoptysis  to  pulmonary  tuberculosis 
and  a  common  cause  of  mistake.  Perhaps  the  heart  is  not  examined 
at  all,  or  if  it  be  examined  it  is  by  no  means  rare  for  the  characteristic 
murmur  to  be  absent.  Furthermore,  because  there  are  frequently 
apical  signs,  as  has  already  been  indicated,  phthisis  is  often  diagnosed. 
In  several  cases  I  was  nearly  trapped  by  this  similarity  of  mitral 
disease  to  phthisis,  but  noting  some  irregularity  in  the  heart  beat, 
I  investigated  further  and  diagnosed  mitral  stenosis.  It  must  always 
be  remembered  that  while  active  phthisis  is  not  altogether  exluded 
with  heart  disease,  yet  it  is  extremely  rare,  especially  in  mitral  stenosis. 

Hemoptysis  in  Bronchiectasis  and  Syphilis  of  the  Lungs. — In  bron- 
chiectasis bleeding  is  not  uncommon,  and  I  have  seen  copious  hemor- 
rhages due  to  this  cause.  The  blood  is  derived  either  from  dilated 
and  congested  bloodvessels  in  the  proliferated  mucous  membrane, 
or  from  inflammatory  changes  in  the  mucosa,  or  from  small  corroded 
aneurisms  in  the  walls  of  bronchiectatic  cavities,  similar  to  those 
found  in  tuberculous  excavations.  As  a  rule  it  is  encountered  in  older 
persons.  During  the  hemorrhage  the  diagnosis  may  be  difficult, 
though  a  careful  history  clears  up  the  case.  In  syphilis  of  the  lungs, 
hemoptysis  of  various  degrees  has  been  encountered. 

Menstrual  Hemoptysis. — Phthisical  women,  if  they  are  to  have 
hemoptysis  at  all,  are  more  apt  to  have  it  during  the  menstrual  period. 
It  has  been  observed  that  during  menstruation  there  is  usually  an 
increased  blood-pressure  and  a  congestion  of  the  laryngeal  mucous 
membrane,  and  some  state  that  active  periodical  hyperemia  of  the 
lungs  occurs  at  that  time  and  this  would  favor  extravasation  of  blood, 
especially  in  the  affected  area.  According  to  Macht^  these  periodical 
hemorrhages,  which  may  be  very  slight  or  profuse,  may  persist  after 
the  patient  has  improved  in  health  and  the  tuberculous  process  becomes 
arrested.  Periodic  hemorrhages  in  consumptives  at  the  time  of 
menstruation  may  take  place  from  other  organs  than  the  lungs.  Thus, 
Wilson  and  Newman  have  reported  such  hemorrhages  from  the 
trachea  and  upper  respiratory  ])assages.    ]\Tacht  also  reports  a  rather 


1  Brit.  Med.  .Jour.,  1912,  i,  2.S7. 

2  Amer.  Jour.  Med.  Sci.,  1910,  exl,  835. 


DIAGNOSTIC  SIGNIFICANCE  OF  HEMOPTYSIS  197 

interesting  case  of  a  woman  with  pulmonary  tuberculosis  with  in- 
testinal complications — ulcer  in  the  bowels — who  regularly  had  severe 
hemorrhages  from  her  intestines  at  her  periods. 

Vicarious  menstruation,  which  is  very  rare,  appears  to  be  due  in 
most  cases  to  tuberculosis.  But  in  evaluating  vicarious  menstruation 
it  must  be  borne  in  mind  that  amenorrhea  is  very  frequent  in  phthisis, 
and  in  this  disease  hemoptysis  is  frequent;  it  is  therefore  not  surprising 
that  hemoptysis  should  occasionally  occur  while  the  menstrual  flow 
has  been  delayed  or  suppressed. 

Localization  of  the  Source  of  the  Hemorrhage. — Heretofore  the  deter- 
mination of  the  side  of  the  chest  in  which  the  bleeding  takes  place 
was  merely  of  academic  interest  because  it  made  very  little  difference 
on  which  side  the  ice-bag,  which  has  been  traditionally  used  in  the 
treatment  of  this  symptom,  was  applied.  But  recently,  since  we  found 
that  an  artificial  pneumothorax  may  stop  a  copious  hemorrhage  after 
everything  else  has  failed,  it  is  of  practical  importance  to  localize  the 
bleeding-point. 

In  cases  which  have  been  under  observation  for  some  time  and  it  is 
known  that  the  lesion  is  unilateral,  the  problem  may  be  simple,  inas- 
much as  profuse  bleeding  implies  an  old  cavitary  lesion.  But  in 
bilateral  cases  it  is  difficult,  often  impossible,  to  determine  positively 
which  lung  is  bleeding.  Percussion  must  not  be  done  for  fear  of  in- 
creasing the  bleeding  and  ausculation  may  be  of  service  in  showing 
a  limited  area  of  moist,  consonating  rales,  and  perhaps  amphoric 
breath-sounds.  But  it  is  a  noteworthy  fact,  which  must  never  be  lost 
sight  of,  that  during  profuse  hemorrhages  the  blood  may  be  aspirated 
into  the  non-bleeding  lung  and  produce  all  sorts  of  rales.  It  is 
therefore,  at  times,  impossible  to  decide  positively  which  lung  is 
bleeding. 

In  rare  cases  we  hear  murmurs,  synchronous  with  the  heart  beat, 
over  the  site  of  excavations.  Gerhardt  found  that  these  murmurs 
originate  in  arteries  which  traverse  the  walls  of  cavities  and  he  veri- 
fied his  observations  at  the  autopsy  table.  In  several  cases  this 
phenomenon  was  observed  by  me,  the  murmur  was  audible  below 
the  clavicle,  and  over  the  same  area  were  most  of  the  classical  signs 
of  pulmonary  excavation.  These  patients  are  apt  to  bleed  copiously, 
and  they  often  succumb  to  a  sharp  hemorrhage.  Here  we  know  that 
the  source  of  the  bleeding  is  the  branch  of  the  pulmonary  artery 
which  traverses  the  cavity,  and  operative  treatment  (an  artificial 
pneumothorax)  may  be  attempted  when  a  hemorrhage  cannot  be 
controlled  otherwise.  But  these  cases  are  rare  and  in  the  average 
case  we  cannot  say  with  any  degree  of  certainty  that  the  bleeding 
vessel  is  located  in  a  superficially  recognized  excavation,  and  not  in 
another  one,  either  located  deeper,  or  altogether  in  the  other  half  of 
the  chest.  I  have  repeatedly  seen  cases  in  which  after  a  copious 
hemorrhage  the  more  affected  side  remained  unaltered,  while  in  the 
unaffected  lung  new  rales  appeared. 


198  ■  HEMOPTYSIS 

According  to  Strieker/  the  bleeding  comes  from  an  eroded  vessel 
when  it  occurs  suddenly  during  the  course  of  acute  and  progressive 
phthisis,  while  in  chronic  cavitary  phthisis  it  is  usually  derived  from 
an  aneurismal  dilatation  of  a  vessel.  Repeated  hemorrhages  accom- 
panied by  fever  point  to  progressive  decay  of  the  affected  area  in  the 
lung.  Hemoptysis  in  the  advanced  stages  of  phthisis  is  derived  from 
eroded  arteries,  and  for  this  reason  the  prognosis  is  less  favorable 
than  in  hemoptysis  in  incipient  cases  or  in  initial  hemorrhages,  which 
are,  as  a  rule,  of  venous  origin. 

Differential  Diagnosis. — In  cases  of  initial  hemoptysis  it  is  impera- 
tive to  ascertain  whether  the  blood  is  derived  from  a  tuberculous 
lesion  or  is  due  to  some  other  cause.  Careful  examination  of  the  nose 
and  throat  may  reveal  that  it  is  altogether  due  to  congestion  or 
varicosity  of  these  mucous  membranes,  as  has  already  been  mentioned. 
When  the  sanguinous  fluid  expectorated  is  uniformly  bright  red  and 
watery,  it  is  in  all  probabilities  derived  from  the  mouth.  In  case  no 
symptoms  or  signs  of  a  pulmonary  lesion  are  discovered,  and  the  bleed- 
ing cannot  be  ascribed  to  a  non-tuberculous  condition,  the  heart  is 
normal  and  there  is  no  history  of  an  injury,  the  patient  is  to  be  placed 
under  prolonged  observation  before  deciding  that  he  is  not  tuberculous. 
But  it  must  always  be  borne  in  mind  that  mere  streaks  in  the  sputum 
may  be  due  to  many  causes  other  than  tuberculosis  of  the  lungs,  and  a 
diagnosis  of  phthisis  should  not  be  made  because  of  their  presence 
alone. 

In  copious  hemorrhage,  when  it  is  not  feasible  to  examine  the 
patient's  chest  carefully,  it  is  often  difficult  to  decide  whether  the 
bleeding  is  due  to  a  tuberculous  lesion,  a  bronchiectatic  cavity,  pul- 
monary syphilis  or,  in  rare  cases,  whether  it  is  not  altogether  hema- 
temesis.  The  last-mentioned  condition  may  simulate  hemoptysis 
because  the  patient  may  have  aspirated  the  blood  into  the  respiratory 
passages  and  then  expectorated  it;  while  in  hemoptysis  the  blood  may 
be  swallowed  and  then  vomited.  It  may  then  greatly  simulate  blood 
derived  from  the  stomach,  viz.,  black  or  chocolate-colored,  thick 
lumps  or  clots,  mixed  with  the  contents  of  the  stomach.  I  have  met 
with  cases  in  which  the  diagnosis  could  not  be  made  immediately. 
We  may,  however,  be  guided  by  the  following  points:  In  hemoptysis 
the  blood  is,  as  a  rule,  coughed  up,  bright  red,  frothy  and  mixed  with 
sputum.  It  is  also  alkaline  and  does  not  clot.  Auscultation  may 
reveal  rales  in  some  part  of  the  chest,  and  a  careful  history  will  show 
that  the  patient  has  been  coughing,  expectorating,  etc.,  for  a  long 
time,  while  in  cases  of  hematemesis  the  history  points  to  disturbances 
in  the  gastric  functions,  and  physical  signs  may  be  discovered  in  the 
abdomen.  In  hemoptysis  we  invariably  observe  that  after  the  cessa- 
tion of  active  bleeding  the  patient  keeps  on  coughing  and  expectorating 
clotted  blood  for  several  days,  which  is  never  observed  in  hematemesis. 

1  Nothnagel's  Handbuch  d.  spcz.  Pathol.,  xiv,  7. 


PROGNOSIS  IN  INITIAL  TUBERCULOUS  HEMOPTYSIS      199 

But  when  the  hemorrhage  from  either  source  is  brisk  and  copious, 
and  there  is  no  history,  the  points  just  enumerated  are  often  of  no 
value,  because  the  blood  is  bright  red,  alkaline,  and  not  mixed  with 
either  sputum  or  gastric  contents.  But  such  profuse  hemorrhages 
are  only  seen  in  advanced  consumptives  and  there  are  always  to  be 
noted  the  stigmata  of  tuberculosis. 

In  cases  in  which  the  diagnosis  has  not  been  previously  established, 
bleeding  from  the  deeper  respiratory  passages  may,  on  rare  occasions, 
be  difficult  of  differentiation  as  to  whether  it  is  derived  from  a  tuber- 
culous lesion  or  from  a  bronchiectatic  cavity.  I  have  been  guided 
by  the  pulse  and  temperature  of  the  patient — when  these  are  normal, 
and  the  general  condition  of  the  patient  is  good,  the  chances  are  that 
there  is  a  bronchiectatic  cavity,  especially  in  persons  over  forty-five 
years  of  age.  In  older  persons  with  arteriosclerosis  the  so-called 
"arthritic  diathesis"  is  to  be  thought  of.  Usually  a  careful  history 
clears  up  the  diagnosis,  while  in  rare  borderline  cases  we  should 
reserve  our  opinion  till  the  hemorrhage  ceases  and  a  careful  examina- 
tion of  the  patient  is  feasible. 

In  addition  to  tuberculosis  the  following  conditions  are  liable  to 
cause  pulmonary  hemorrhage:  Cardiac  disease,  hemophilia,  bron- 
chiectasis, syphilis,  abscess  and  gangrene  of  the  lung,  certain  acute 
specific  fevers,  pneumonia,  suppurative  processes  in  the  mediastinum, 
foreign  bodies  in  the  bronchi,  injuries  to  the  chest,  paroxysms  of 
pertussis,  echinococcus,  cancer,  actinomycosis,  aspergilosis,  hydatid, 
distoma  pulmonum,  and  pneumokoniosis. 

Prognostic  Significance  of  Hemoptysis. — Patients,  almost  without 
exception,  overestimate  the  significance  of  hemoptysis  and  are  more 
terrified  at  the  appearance  of  a  speck  of  blood  in  their  sputum  than 
by  any  other  symptom  or  complication  of  phthisis,  excepting  perhaps 
spontaneous  pneumothorax.  It  is  for  this  reason  that  initial  hemop- 
tysis has  been  described  by  some  authors  as  a  salutary  phenomenon, 
because  it  draws  the  attention  of  the  patient  to  the  condition  of  his 
lungs  which  he  may  have  otherwise  neglected.  In  fact,  I  have  known 
cases  in  which  hemoptysis  was  actually  life-saving  for  just  this  reason 
in  patients  who  had  coughed  for  months  and  presented  other  symp- 
toms of  phthisis  which  they  considered  a  trifling  affair,  when,  like  the 
climax  of  a  slowly  developing  drama,  hemoptysis  made  its  appearance, 
opening  their  eyes,  or  even  those  of  their  physicians,  so  that  proper 
treatment  was  instituted. 

A  hemorrhage  may  prove  fatal  immediately  or  within  a  few  days 
of  its  appearance;  or,  if  the  patient  survives  it,  it  may  have  an  in- 
fluence on  the  course  of  the  disease. 

Prognosis  in  Initial  Tuberculous  Hemoptysis. — We  have  already 
mentioned  that  many  cases  of  pulmonary  hemorrhage,  even  when 
due  to  tuberculous  lesions,  are  not  necessarily  followed  by  symptoms 
of  phthisis.  Every  physician  has  among  his  clientele  patients  who 
have  coughed  out  more  or  less  blood  years  ago  and  have  never  suffered 


200  HEMOPTYSIS 

from  disease  of  the  lungs.  "Outspoken  tuberculosis  does  not  neces- 
sarily follow  hemoptysis,"  says  Frederick  T.  Lord/  "which  may 
occur  in  patients  with  apparent  good  health  and  sound  lungs.  Of 
329  instances  of  hemoptysis  observed  by  Ware.  62  (IS  per  cent.) 
recovered  without  subsequent  symptoms  to  suggest  pulmonary  tuber- 
culosis. The  interval  elapsing  between  the  attack  of  hemoptysis  and 
the  last  report  was  over  ten  years  in  41  cases.  In  1768  Goethe,  at  the 
age  of  nineteen  years,  and  then  a  student  at  Leipzig,  had  an  attack 
as  follows:  'One  night  I  waked  with  a  severe  hemoptysis  and  had 
enough  strength  and  presence  of  mind  to  wake  my  room-mate  .  .  . 
for  several  days  I  wavered  between  life  and  death.'  For  some  months 
he  thought  he  had  pulmonary  tuberculosis  and  must  die  young. 
At  the  age  of  eighty-two  years  he  had  hemoptysis  again  and  died  at 
the  age  of  eighty- three  years.  His  long  and  active  life  may  serve  as 
a  comforting  example  to  those  who  need  encouragement.  At  the  age 
of  twenty-three  or  twenty-four  years,  Rousseau  expectorated  blood 
and  gave  up  his  work  as  a  teacher  of  singing.  He  died  at  the  age  of 
sixty-six." 

Proportion  of  Deaths  due  to  Pulmonary  Hemorrhages. — ^When  profuse, 
the  patient  may  be  exsanguinated  and  succumb  to  cerebral  anemia, 
or  the  blood  may  overflow  the  bronchial  tree  and  suffocate  him, 
especially  when  it  occurs  suddenly  while  the  patient  is  asleep.  While 
this  outcome  is  seen  now  and  then,  it  is  a  very  rare  occurrence.  Louis 
had  but  3  fatal  cases  in  300  consumptives;  Williams  4  out  of  198 
fatal  cases;  Wilson  Fox  4  out  of  101;  Moeller  saw  only  1  fatal 
hemoptysis  during  fifteen  years'  experience  with  consumptives;  Wolff 
reports  a  lethal  outcome  three  times  among  1200  tuberculous  patients 
(0.25  per  cent.);  Winsch  1  among  200  (0.5  per  cent);  Thue,  13  times 
among  975  patients  (1.6  per  cent.);  Sorgo  14  deaths  among  5800 
consumptives  (2.4  per  cent.)  and  among  2.16  per  cent,  of  his  patients 
subject  to  hemoptysis.  Lord  reports  that  death  as  an  immediate 
result  of  bleeding  occurred  in  only  1  of  76  patients  with  hemoptysis 
at  the  Channing  Home,  and  2  of  142  at  the  Massachusetts  General 
Hospital.  Death  as  a  consequence  of  extension  of  pulmonary  infec- 
tion for  which  the  hemorrhage  was  responsible,  occurred  in  1  case 
at  the  Channing  Home  and  6  other  cases  at  the  Massachusetts  General 
Hospital. 

Williams  reports  that  in  1000  cases,  including  63  fatal  ones,  where 
the  patients  had  hemoptyses  of  one  ounce  and  upward  on  one  or  more 
occasions,  the  average  duration  was  seven  years  and  six  months; 
an  average  differing  only  by  a  few  months  from  that  of  the  total 
deaths.  In  200  living  cases  of  similarly  extensive  hemoptysis,  the 
average  was  eight  years  and  three  months — about  the  same  as  that  of 
the  living  cases  generally.  "  It  is  only  in  the  far-advanced  stages  that 
it  is  likely  to  curtail  the  duration  of  the  disease.     In  early  cases  hemop- 

1  Diseases  of  the  Bronchi,  Lungs,  and  Pleura,  Philadelphia,  1915,  p.  360. 


PROGNOSIS  IN  INITIAL  TUBERCULOUS  HEMOPTYSIS     201 

tysis  is  comparatively  unimportant,"  concludes  Williams.  When  we 
say  that  hardly  one  out  of  a  thousand  deaths  due  to  tuberculosis  is 
caused  by  hemorrhage,  we  are  as  near  the  true  figure  as  possible. 

Influence  of  Hemoptysis  on  the  Course  of  Phthisis. — The  influence  of 
hemorrhage  on  the  course  of  the  disease  is  misunderstood  by  the 
average  patient  and  often  overestimated  by  the  physician.  It  may  be 
said  that  as  long  as  it  does  not  prove  fatal  immediately,  and  this  is 
rare  as  we  have  just  shown,  it  has  no  effect  on  the  patient  nor  on  the 
disease.  Many  older  writers  have  stated  that  it  often  has  a  rather 
salutary  effect,  and  not  altogether  without  reason,  as  is  proved  by  the 
course  of  many  cases  subsequent  to  hemorrhages.  Lebert,  Flint, 
Wilson  Fox  and  others  state  that  hemorrhages  may  produce  a  sense 
of  relief,  and  cough  and  expectoration  previously  existing  may  tem- 
porarily disappear.  Williams  says  ^'  To  many  patients  its  occurrence 
seems  beneficial  rather  than  otherwise,  for  the  congestion  is  thus 
relieved  and  the  system  not  materially  weakened  by  the  loss  of  blood." 
I  have  seen  many  cases  in  whom  the  disease  took  a  turn  for  the  better 
soon  after  a  more  or  less  profuse  hemorrhage,  and  others  in  which  the 
cough,  anorexia,  pains  in  the  chest,  etc.,  disappeared  after  this  accident. 
We  know  that  slight  abstraction  of  blood  is  often  beneficial  inasmuch 
as  it  stimulates  the  blood-forming  organs  to  produce  more  blood  cells. 

The  fear,  formerly  entertained,  that  the  blood,  spreading  all  over 
the  bronchial  tree,  is  apt  to  inoculate  new  areas  and  produce  new  lesions 
in  hitherto  unaffected  parts  of  the  lung,  is  now  known  to  be  without 
sound  foundation  because  reinfection  is  difficult  or  even  impossible 
in  the  vast  majority  of  cases.  To  be  sure,  we  find  that  the  bronchi 
contain  blood  while  auscultating  a  patient  during,  or  immediately 
after,  a  hemorrhage,  but  this  is  usually  transitory,  disappearing  by 
absorption  or  expectoration  within  a  few  days  after  the  bleeding 
ceases  and  the  original  pulmonary  lesion,  if  not  progressive,  remains 
the  same  as  it  was  before,  pursuing  the  same  course  as  if  no  such 
accident  had  occurred.  Cases  in  which  after  a  hemorrhage  a  quiescent 
lesion  begins  to  pursue  an  acute  or  subacute  course,  and  tuberculous 
bronchopneumonia  is  found  at  the  autopsy,  are,  in  all  probabilities, 
due  to  a  sudden  reduction  in  the  powers  of  resistance,  about  the  causes 
of  which  we  know  nothing  at  present.  They  do  occur  now  and  then, 
but  when  taken  in  connection  with  the  large  number  of  hemoptyses 
in  which  this  sequel  does  not  occur,  they  are  comparatively  rare. 

More  than  sixteen  hundred  years  ago  Galen  stated  that  the  prognosis 
of  pulmonary  hemorrhage  depends  on  the  fever  which  is  apt  to  ac- 
company it — afebrile  cases  recover,  while  in  febrile  cases  the  prognosis 
is  gloomy.  More  extended  experience  in  recent  years  has  confirmed 
the  opinion  of  this  ancient  and  empirical  clinician. 

In  hemoptysis  the  immediate  and  especially  the  ultimate  prognosis 
depends  less  on  the  bleeding,  its  abundance  or  even  repetition,  than 
on  the  extent  of  the  pulmonary  lesion  and  the  symptoms  which 
accompany  or  dominate  the  clinical  picture,  the  subsequent  course 


202  -HEMOPTYSIS 

of  the  original  disease — phthisis — and  the  comphcations  which  may 
arise.  When  we  find  during  a  hemorrhage  that  a  patient  has  a  good, 
full  pulse,  less  than  100  in  frequency,  and  no  fever  or  dyspnea,  the 
immediate  prognosis  is  good.  If  there  are  several  repetitions  of  the 
hemorrhage  during  the  subsequent  few  days,  the  prognosis  is,  as  a 
rule,  favorable  as  long  as  the  pulse  is  good  and  there  is  no  fever. 
Even  fever  is  of  no  grave  significance  if  it  lasts  but  a  couple  of  days. 
It  is  then  due  to  absorption  of  the  blood  remaining  in  the  bronchi.  It 
is  only  when  the  fever  is  high  and  persistent  for  several  days  that  it 
assumes  serious  significance. 

In  case  the  pulse  becomes  small,  soft,  compressible  and  rapid  we 
may  be  sure  that  the  bleeding  continues  even  if  we  do  not  see  it 
brought  up  in  large  quantities  through  the  mouth,  for  we  may  have 
internal  hemorrhage  in  phthisis,  the  blood  being  retained  in  a  large 
cavity,  while  the  feeble  patient  is  unable  to  force  it  out  by  cough. 
This  is  especially  apt  to  occur  after  large  doses  of  morphine  have  been 
administered,  or  in  severely  emaciated  persons. 

In  cases  which  had  been  active  before  the  onset  of  the  bleeding, 
having  had  fever,  tachycardia,  emaciation,  etc.,  the  prognosis  after 
cessation  of  the  bleeding  is  usually  the  same  as  it  would  have  been  had 
there  been  no  such  complication.  The  temperature  usually  drops 
during  a  brisk  hemorrhage,  but  it  rises  again  and  the  course  of  the 
disease  continues  unabated.  But  if  the  temperature  has  been  normal, 
or  only  slightly  above,  and  the  pulse  is  less  than  100,  full  and  bounding, 
the  patient  has  a  good  appetite,  and  sedative  drugs  are  judiciously, 
if  at  all,  administered,  the  immediate  as  well  as  the  ultimate  outlook 
is  indeed  good. 

In  most  cases  the  findings  on  physical  exploration  of  the  chest 
after  moderate  hemoptysis  remain  the  same  as  they  were  before  that 
event,  although  on  auscultation  we  usually  hear  moist,  consonating 
rales  which  may  not  have  been  there  before  the  onset  of  bleeding. 
These  rales  may  persist  for  several  weeks.  In  some  cases  we  find  that 
the  area  of  dulness  over  the  upper  lobe  extends  because  of  caseous  or 
necrotic  changes  engendered  during  the  hemorrhage.  This  dulness 
may  disappear  after  the  clots  have  been  absorbed,  or  after  the  resolu- 
tion of  the  pneumonic  areas.  More  frequently  it  is  in  time  supplanted 
by  tympany  due  to  excavation. 


CHAPTER  XI. 

SYMPTOMS  CAUSED  BY  DISTURBANCES  IN  THE 

GASTRO-INTESTINAL  TRACT— THE  SKIN— 

THE  JOINTS. 

GASTRO-INTESTINAL   SYMPTOMS. 

Frequency. — Some  authors  have  stated  that  phthisis  develops  mostly 
in  individuals  who  have  been  naturally  bad  eaters;  others  have  main- 
tained that  those  suflfering  from  gastric  derangement  are  most  likely 
to  fall  prey  to  the  disease,  and  Grancher  says  that  "  all  consumptives 
have  been,  are,  or  will  become,  dyspeptics."  In  practice  we  meet 
with  many  patients  who  have  been  treated  for  gastritis  for  a  long 
time  until  the  true  nature  of  their  disturbance  became  evident.  The 
diagnostic  and  especially  the  prognostic  significance  of  anorexia  or 
gastritis  in  a  disease  which  depends  in  its  origin  and  outlook  on 
proper  nutrition  cannot  be  overestimated. 

As  far  back  as  1826  Wilson  Philip^  drew  attention  to  the  fact 
that  many  cases  of  phthisis  are  preceded  for  some  time  by  severe 
indigestion.  In  his  excellent  monograph  on  the  "Dyspepsia  of  Phthisis," 
W.  Soltau  Fenwick"^  quotes  Todd,  Sir  James  Clark,  Budd,  Bennett, 
Ansell  and  other  writers  of  the  first  half  of  the  nineteenth  century 
to  the  effect  that  dyspepsia  is  a  very  frequent  forerunner  of  phthisis. 
In  those  days  some  authors  even  spoke  of  "gastric  phthisis,"  and 
"  pretuberculous  dyspepsia"  is  even  now  mentioned  by  some  authors. 
There  is  no  doubt  that  incipient  phthisis,  as  we  know  it  at  present, 
was  in  those  days  not  recognized,  and  this  was  responsible  for  the 
notion  that  phthisis  is  often  preceded  by  dyspepsia. 

Recent  investigations,  however,  do  not  confirm  that  gastro-intes- 
tinal  disturbances  are  -per  se  predisposing  factors  in  the  evolution  of 
phthisis,  though  Fenwick  says  that  for  his  own  part  he  is  quite  con- 
vinced that  there  does  exist  a  variety  of  dyspepsia  which  is  peculiarly 
apt  to  be  followed  by  pulmonary  tuberculosis. 

As  an  early  symptom  of  phthisis,  dyspepsia  is  quite  frequent.  Hutch- 
inson^ found  it  in  92  per  cent,  of  his  cases,  and  in  55  per  cent,  it  was 
quite  severe.  Samuel  Fenwick,  Dobell,  Pollock,  and  others  have 
found  it  in  nearly  similar  proportions.  W.  Soltau  Fenwick  states 
that  ■'  dyspeptic  phenomena  of  sufficient  severity  to  attract  the  atten- 
tion of  the  patient  are  encountered  in  about  70  per  cent,  of  all  cases 
of  early  phthisis,  but  that  the  early  development  of  the  disorder  in 
any  individual  case  depends  to  a  great  extent  upon  the  sex  of  the 

1  Treatise  on  Indigestion,  London,  1826,  p.  323. 
^  The  Dyspepsia  of  Phthisis,  London,  1894. 
•'  Medical  Times,  1855,  i,  583. 


204    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

patient,  the  type  of  the  tubercular  disease  and  the  previous  condition 
of  the  digestive  organs."  He  found  that  it  is  more  apt  to  occur  in 
females  than  in  males  and  in  general  in  that  variety  of  phthisis  which 
commences  insidiously  and  progresses  slowly. 

More  recent  investigations  have  onl}^  partly  confirmed  the  findings 
of  the  above-mentioned  clinicians,  and  there  are  writers  who  consider 
anorexia,  though  not  a  result  of  gastritis,  a  constant  symptom  of 
incipient  phthisis,  like  fever,  cough,  nightsweats,  emaciation,  etc. 
An  analysis  of  3007  cases  in  the  Phipps  Institute  showed  that  55.3 
per  cent,  presented  symptoms  referable  to  the  stomach.  It  appears, 
however,  as  H.  R.  M.  Landis^  shows,  that  these  gastric  disturbances  were 
in  no  way  due  to  changes  in  the  stomach  peculiar  to  tuberculosis 
itself;  the  changes  being  such  as  might  occur  in  any  chronic  wasting 
disease.  Janowski^  reports  that  among  700  patients,  35  per  cent, 
suffered  from  gastric  disturbances,  which  were  more  often  encountered 
in  women  than  in  men.  With  this  Kuthy  is  also  in  agreement.  He 
found  that  in  37.3  per  cent,  of  his  male  patients  there  were  gastric 
disturbances  as  against  50.1  per  cent,  in  his  female  patients.  In  the 
first  stage,  38  per  cent.;  in  the  second  stage,  46.4  per  cent.;  and  in 
the  third  stage  57.2  per  cent,  showed  these  symptoms. 

Symptomatology. — One  of  the  characteristics  of  the  anorexia  of 
phthisis  is  that,  unlike  the  appetite  in  other  diseases,  it  is  inde- 
pendent of  the  fever  in  many  cases.  Many  patients  with  but  slight 
fever  have  an  almost  complete  antipathy  for  food,  while  others  who 
have  moderate  fever,  preserve  an  excellent  appetite.  Lasegue  said 
"all  patients  who  eat  and  digest  their  food  well  despite  having  fever 
are  consumptives."  In  acute  pneumonic  phthisis,  which  is  often 
difficult  to  differentiate  from  lobar  or  lobular  pneumonia,  I  have 
placed  great  reliance  on  this  symptom:  In  pneumonia  the  anorexia 
is  invariably  complete,  while  in  acute  phthisis  the  appetite  may  be 
retained  more  or  less,  and  in  spite  of  a  temperature  of  103°  or  104°  F. 
the  patient  is  apt  to  ask  for  nourishment. 

In  incipient  phthisis  the  appetite  is  often  very  capricious.  One 
day  a  certain  food  is  preferred  while  the  next  it  is  despised  and  morbid 
cravings  are  not  uncommon,  especially  in  women.  A  large  proportion 
of  patients  cannot  tolerate  certain  kinds  of  food — some  will  not  eat 
meat,  others  refuse  milk,  eggs,  etc.  It  seems  to  me,  however,  that 
the  repugnance  for  milk  and  eggs  is  often  not  the  result  of  the  tuber- 
culous process,  but  is  an  acquired  characteristic  due  to  the  stuffing 
with  these  articles  of  food  which  is  so  commonly  carried  to  an  extreme 
degree.  Following  the  usual  advice  "plenty  of  milk  and  eggs"  is  likely 
to  ruin  an  excellent  appetite  if  carried  to  extremes.  Two  or  three 
quarts  of  milk  and  half  or  one  dozen  of  raw  eggs  daily,  which  tuber- 
culous patients  often  consume,  may  result  in  a  strong  repugnance 
to  these  articles. 

1  Trans.  Nat.  Assn.  Study  and  Prev.  Tuber.,  1910,  vi,  19.3. 

2  Zeitschr.  f.  Tuberkulose,  1907,  x,  493. 


GASTRO-INTESTINAL  SYMPTOMS  205 

An  aversion  to  fats  of  any  kind  is  very  frequently  observed  in 
phthisical  patients.  Hutchinson  noted  this  fact  overy  sixty  years 
ago  and  stated  that  71  per  cent,  of  his  phthisical  patients  disliked 
fats;  33  per  cent,  could  take  them  in  but  small  quantities;  while 
only  5  per  cent,  liked  them.  Fenwick  noted  a  marked  aversion  to  fat 
in  64  per  cent.,  and  many  of  his  patients  developed  this  peculiar 
antipathy  many  months  or  even  years  before  the  onset  of  the  pul- 
monary disease.  He  observed  that  among  families  which  exhibit  a 
marked  predisposition  to  tuberculosis,  it  is  not  uncommon  to  find 
that  several  members  possess  a  strong  aversion  to  all  forms  of  fat 
and  are  often  unable  to  partake  of  even  a  small  quantity  of  this 
material  without  suffering  from  acidity,  nausea  or  attacks  of  bilious- 
ness. Occasionally  we  meet  with  tuberculous  patients  who  dislike 
carbohydrate  and  especially  saccharine  foods,  the  ingestion  of  which 
causes  more  or  less  severe  gastric  discomfort. 

In  many  cases  the  anorexia  improves  with  the  improvement  in 
the  local  condition  in  the  lung;  but  we  also  meet  with  cases  in  which 
the  tuberculous  lesion  is  slowly  progressing  or  quiescent,  but  the 
appetite  improves,  as  if  the  organism  had  adapted  itself  to  the  tuber- 
culous toxemia.  In  fact  almost  insatiable  hunger  may  be  seen  on 
rare  occasions. 

In  the  early  stages  of  phthisis  digestion  is  fair  or  good  in  most  cases. 
Indeed,  it  appears  to  me  that  digestion  in  phthisis  usually  depends 
on  the  condition  of  the  gastro-intestinal  tract  before  the  onset  of  the 
lung  disease.  As  was  already  intimated,  the  excessive  quantities  of 
milk  and  raw  eggs  may  be  responsible  for  the  symptoms  of  dyspepsia 
in  many  cases,  such  as  pyrosis,  belching,  flatulence,  bad  taste  in  the 
mouth,  etc.  The  fact  that  these  symptoms  may  be  removed  by  appro- 
priate corrections  in  the  diet  is  in  favor  of  our  contention.  Except- 
ing in  advanced  cases  and  in  alcoholics,  vomiting,  if  it  occurs  at  this 
stage,  is  due  to  cough,  as  has  already  been  detailed  when  speaking 
of  the  emetic  cough.  It  is  also  likely  to  be  preceded  by  nausea,  which 
is  not  the  fact  with  the  emetic  cough. 

Causes  of  Anorexia. — It  appears  that  the  anorexia  of  phthisis  is  of 
toxic  origin.  Analyses  of  the  gastric  contents  have  not  revealed  any 
constant  changes  in  the  anatomy  or  functional  activity  of  the  stomach 
in  the  early  stages  of  phthisis.  In  some  cases  hyperchlorhydria  is 
found,  in  others  hypochlorhydria,  while  in  many  others  the  free 
and  combined  acids  remain  in  about  normal  proportions.  Nor  have 
any  constant  secretory  or  motor  disturbances  been  observed.  The 
physiology  and  pathology  of  the  stomach  in  early  phthisis,  as  studied 
by  Klemperer,  Hayem,  Einhorn,  Brieger,  Fenwick  and  others  show 
no  characteristic  functional  changes. 

Many  French  authors,  notably  Marfan,^  are  of  the  opinion  that 
the  gastric  symptoms  in  early  phthisis  are  due  to  the  general  anemia 

1  Troubles  et  lesions  gastriques  dans  la  phtisie  pulmonaire,  Paris,  18S7. 


206    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

which  causes  sluggish  secretion  of  gastric  juice,  weakness  of  the 
smooth  musculature  and  hyperesthesia  of  the  gastric  nerve  endings 
of  the  vagus.  Fenwick,  finding  that  the  dyspepsia  in  phthisis  is  not 
a  direct  result  of  pyrexia,  nor  of  direct  irritation  of  the  mucous  mem- 
brane, concludes  that  it  is  probably  due  to  the  chronic  absorption  of 
certain  toxic  substances  which  are  manufactured  in  the  pulmonary 
cavities;  but  he  describes  a  form  of  dyspepsia  which  often  precedes 
the  development  of  pulmonary  tuberculosis,  when  cavities  are  out 
of  the  question. 

The  gastric  symptoms  appear  to  be  analogous  with  those  observed 
in  chlorosis  and  the  severe  anemias  which  cause  ischemia  of  the 
digestive  tract.  But  as  Janowski  points  out,  many  tuberculous  patients 
without  any  anemia  also  suffer  from  gastric  symptoms,  and  he  con- 
cludes therefore  that  the  anorexia  is  not  invariably  due  to  general 
anemia,  but  to  ischemia  of  the  gastric  and  intestinal  mucosa.  This 
explains  why  so  many  different  results  have  been  obtained  from 
analyses  of  the  gastric  contents.  It  is  the  paroxysmal  proclivity  of 
the  gastric  disturbances  which  is  characteristic  of  early  phthisis. 

Gastric  Symptoms  in  Advanced  Phthisis. — The  anorexia  and  other 
gastric  symptoms  of  early  phthisis  usually  subside  in  cases  pursuing 
a  favorable  course  and  the  patients  recover.  But  in  cases  with  pro- 
gressive disease,  especially  those  characterized  by  pulmonary  excava- 
tions, more  or  less  severe  symptoms  of  dyspepsia  are  present.  Nearly 
a  century  ago  Louis  found  that  about  two-thirds  of  his  phthisical 
patients  had  shown  signs  of  dilatation  of  the  stomach.  W.  Soltau 
Fenwick  found  among  100  autopsies  in  cases  of  tuberculosis  in  which 
he  took  special  notes  on  this  point,  that  the  lower  margin  of  the  viscus 
extended  below  the  level  of  the  navel  in  64  and  he  says  that  it  is 
rare  while  performing  an  autopsy  on  a  phthisical  subject  to  fail 
to  encounter  some  increase  in  the  dimensions  of  this  viscus.  The 
degree  of  gastrectasis  appears  to  bear  a  direct  relation  to  the  extent 
and  chronicity  of  the  pulmonary  lesion. 

Chronic  catarrh  is  very  frequent  but  true  tuberculous  ulcers  are 
exceedingly  rare,  probably  because  the  stomach  contains  very  little 
lymphoid  tissue  and  bacilli  cannot  reach  there  through  this  channel, 
and  the  acid  secretions  are  inimical  to  the  growth  of  tubercle  bacilli. 
Fenwick,  after  a  careful  search  was  able  to  discover  the  records  of 
24  cases  of  this  affection,  several  of  which  are,  however,  open  to  sus- 
picion; while  among  the  notes  of  2000  necropsies  on  cases  of  phthisis 
performed  at  the  Brompton  Hospital  he  could  find  only  two  instances 
in  which  tuberculous  ulcers  of  the  stomach  were  discovered.  Lauritz 
found  4  cases  of  undoubted  tuberculous  ulcers  in  the  stomach 
among  580;  Melchior  6  in  848  autopsies,  and  Gassmann  6.13  per 
cent,  in  600  autopsies.  There  have  been  reported  cases  of  perfora- 
tion of  tuberculous  gastric  ulcers  into  the  peritoneum,  though  this 
is  exceedingly  rare  because  of  the  inflammatory  adhesions  which 
usuallv  form  around  the  ulcers  and  the  peritoneum.    Simple  gastric 


GASTRO-INTESTINAL  SYMPTOMS  207 

ulcers  are  not  infrequently  found  at  autopsies  on  tuberculous  bodies, 
but  the  proportion  is  not  higher  than  among  patients  who  succumbed 
to  any  cause. 

In  the  vast  majority  of  cases  of  advanced  phthisis  the  appetite  is 
poor;  those  who  do  attempt  to  eat  usually  display  various  distastes 
for  certain  foods,  and  even  this  is  not  constant — the  appetite  is  often 
very  capricious,  and  many  develop  morbid  cravings.  This  is  one 
of  the  difficulties  of  feeding  phthisical  patients  in  sanatoriums  and 
hospitals.  At  times  we  meet  with  patients  who  retain  an  excellent 
appetite  to  the  end  and  cases  of  bulimia  are  not  unknown.  Pain  after 
eating,  pyrosis,  belching,  etc.,  are  very  common  and  vomiting  is  at 
times  a  prominent  symptom.  But  while  the  emetic  cough  may  be 
encountered  in  advanced  cases,  the  vomiting  at  this  stage  is  usually 
not  of  this  type.  They  simply  vomit  because  of  gastritis,  or  dilatation 
of  the  stomach.  This  type  of  vomiting  is  usually  preceded  by  nausea, 
belching,  etc.,  and  not  by  cough  as  in  the  other  type.  The  nausea  and 
retching  may  persist  for  several  hours  after  the  vomiting  and  the 
ejecta  consist  of  sour  food  mixed  with  mucus.  I  have  met  with  cases 
in  which  no  food  could  be  retained  owing  to  vomiting  and  some  even 
with  hematemesis.    The  prognosis  in  these  cases  is  gloomy  indeed. 

In  hectic  cases  the  gastritis  is  often  very  troublesome  and,  com- 
bined with  vomiting,  nightsweats,  cough,  diarrhea,  etc.,  it  is  one 
of  the  terminal  symptoms  of  phthisis.  In  many  cases,  however, 
the  pulmonary  symptoms  overshadow  the  gastric  phenomena,  but 
ver}'  often  the  latter  are  sufficiently  pronounced  to  require  great  care 
and  attention.  The  amyloid  liver  often  contributes  considerably 
to  the  digestive  disturbances,  but  lardaceous  changes  in  the  blood- 
vessels of  the  stomach  are  not  unknown.  I  have  met  with  cases  of 
this  type,  extremely  emaciated,  hardly  able  to  move  a  limb,  yet 
they  asked  for  food  which,  when  given  by  the  nurse,  was  relished 
with  an  apparently  voracious  appetite. 

It  appears  that  the  dyspepsia  of  advanced  phthisis  is  usually  asso- 
ciated with  pulmonary  excavation,  and  is  mainly  caused  by  the 
prolonged  intoxication  characteristic  of  progressive  and  advanced  dis- 
ease. A  fruitful  source  of  gastric  derangement  is  swallowed  sputum, 
more  common  in  women.  The  sputum  not  only  irritates  the  mucous 
membrane  of  the  gastro-intestinal  tract,  but  it  is  also  absorbed  and 
produces  toxemia.  The  mucous  membrane  of  the  gastro-intestinal 
tract  eliminates  poisons  from  the  blood,  which  in  their  turn  irritate 
these  membranes,  as  is  the  case  in  acute  mercurial  poisoning  in  which 
mercurial  albuminates  circulating  in  the  blood  are  eliminated  into 
the  intestines  where  they  cause  severe  diarrhea.  The  injection  of 
large  doses  of  tuberculin  may  also  cause  diarrhea. 

Intestinal  Symptoms. — During  the  incipient  stage  of  phthisis  the 
bowels  are  unaffected  in  most  cases,  though  we  meet  with  constipation 
in  a  large  proportion  of  cases.  But  I  doubt  whether  the  proportion 
is  higher  than  among  people  with  modern  habits  of  life  and  dietetic 


208    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

conditions.  In  some  cases  the  constipation  is  due  to  the  sedative 
medication  used  for  the  control  of  the  cough. 

Diarrhea  may  be  one  of  the  s^Tnptoms  of  incipient  tuberculosis. 
It  is  met  with  mainly  in  patients  at  the  two  extremes  of  life — in 
children  under  ten  years  of  age  and  in  senile  patients.  In  children 
the  diarrhea  may  be  the  only  symptom,  while  examination  of  the  chest 
may  show  nothing  conclusive,  or  signs  of  tracheobronchial  adenopathy 
may  be  found.  In  aged  patients  who  have  felt  quite  well,  even  claim- 
ing that  they  have  not  coughed,  a  chronic  and  persistent  diarrhea 
should  be  considered  a  sign  that  a  careful  examination  of  the  chest  is 
urgent.  It  will  be  found  that  there  are  signs  of  old  phthisical  lesions 
in  the  lungs,  and  the  sputiun  may  contain  numerous  tubercle  bacilli. 
Very  rarely  diarrhea  is  one  of  the  s\Tnptoms  of  incipient  phthisis  in 
young  adults. 

In  some  patients  the  functions  of  the  bowels  remain  more  or  less 
normal  through  the  course  of  the  disease,  but  this  is  rare.  In  most 
cases  diarrhea  makes  its  appearance  with  the  advance  of  the  disease. 
^Yhile  in  many  cases  it  is  due  to  tuberculous  ulceration  of  the  bowels, 
there  are  others  in  which  it  is  caused  by  intestinal  catarrh  very  fre- 
quently the  result  of  dietetic  errors.  In  many  the  ingestion  of  large 
quantities  of  milk  is  responsible  and  eliminating  milk  from  the  diet 
promptly  gives  relief.  In  others  the  excessive  amount  of  fat,  mainly 
eggs,  is  responsible.  Persons  who  have  had  intestinal  trouble  before 
the  onset  of  phthisis  are  more  liable  to  suffer  from  catarrhal  diarrhea 
than  others.  As  will  be  pointed  out  later  when  speaking  of  tuberculous 
ulceration  of  the  intestine,  the  differential  diagnosis  is  exceedingly 
difficult.  The  prognosis  depends  on  the  causation  of  the  diarrhea. 
^Yhen  due  to  amyloid  degeneration  or  .tuberculous  ulceration  of  the 
intestines  the  prognosis  is  grave. 


EMACIATION. 

Emaciation  is  a  cardinal  symptom  of  phthisis;  one  of  the  triad 
mentioned  by  Richard  INIorton,  the  others  being  cough  and  fever. 
Popular  lore,  as  well  as  medical  experience,  have  always  associated 
tuberculosis  with  emaciation.  Phthisis  (Greek,  d'dcacz),  consump- 
tion, has  its  equivalent  in  every  European  language.  That  it  is 
mainly  due  to  the  tuberculous  toxemia  engendered  by  the  metabo- 
lism of  the  tubercle  bacilli  is  evident  from  the  fact  that  experimental 
tuberculosis  is  always  accompanied  by  emaciation  of  the  animals. 

In  acute  galloping  consumption  and  in  miliary  tuberculosis  the 
emaciation  is  progressive  and  frightful,  much  more  rai)id  than  in 
other  febrile  diseases,  as  i)neuinonia,  typlioid,  etc.,  and  this  is  one 
of  the  most  important  ])oiiits  in  the  diflVreiitiatioii  of  acuti^  tulxTcu- 
losis  from  other  acute  diseases.  In  children,  wlien  (hiring  or  after  an 
attack  of  measles,  pertussis,  etc.,  the  wasting  becomes  very  marked 


EMACIATION  209 

and  there  is  dyspnea,  rapid  pulse,  etc.,  acute  tuberculosis  is  to  be 
suspected. 

While  the  denutrition  and  wasting  in  phthisis  is  often  caused  and 
always  enhanced  to  a  certain  extent  by  the  gastro-intestinal  disturb- 
ances which  are  concomitants  of  the  disease  in  all  its  stages,  we 
meet  with  emaciation  almost  constantly  in  active  disease  with  fair 
gastro-intestinal  functions.  Some  authors  are  inclined  to  attribute 
the  emaciation  to  the  lowered  powers  of  absorption  caused  by  a  con- 
genital narrowing  of  the  lymph  channels  in  the  intestinal  tract  which 
is  said  to  predispose  to  phthisis.    But  this  has  not  been  proved. 

Extent  of  Emaciation. — Not  only  is  the  subcutaneous  adipose  tis- 
sue wasting,  but  the  nitrogen-containing  muscles  also  vanish  with 
astonishing  rapidity.  It  is  noteworthy  that  the  first  muscles  to 
waste  are  those  of  the  thorax — the  pectorales,  the  scapular,  the 
intercostals,  etc.  In  many  incipient  cases  we  see  a  striking  contrast 
between  the  wasted  and  flabby  muscles  of  the  chest — and  in  women 
occasionally  the  wasted  breasts — and  the  fairly  preserved  contour  of  the 
muscles  on  the  extremities.  Moreover,  the  muscles  and  subcutaneous 
tissue  of  the  affected  side  of  the  chest  waste  earlier  than  those  on  the 
opposite  and  unaffected  side.  The  result  is  that  the  supraclavicular 
and  supraspinous  fossae  are  more  or  less  deeply  excavated.  This 
characteristic  of  the  muscular  wasting  has  recently  been  made  avail- 
able for  diagnosis  by  the  excellent  studies  of  Pottenger.  In  some 
early  cases  the  face  remains  full  and  is  thus  apt  to  deceive  as  to  the 
state  of  nutrition  of  the  patient  whose  trunk  and  abdomen  are 
markedly  emaciated. 

Effects  of  Emaciation. — The  weakness,  weariness,  loss  of  strength 
and  vigor  of  the  consumptive  are  greatly  due  to  the  muscular  atrophy 
even  in  the  early  stages  of  the  disease,  and  one  of  the  best  signs  of 
improvement  is  the  regression  in  the  muscular  atroph3^  There 
appears  to  be  a  direct  relation  between  emaciation  and  the  course 
of  the  disease.  With  each  extension  of  the  process  in  the  lung,  with 
each  hemorrhage,  he  loses  in  weight,  and  with  each  improvement  he 
gains  in  this  direction,  while  in  quiescent  cases  the  weight  remains 
unaltered.  It  may  be  stated  that,  with  some  exceptions  to  be  men- 
tioned later,  the  scale  may  be  taken  as  a  fair  index  of  the  evolution 
of  phthisis  and  when  we  consider  it  in  connection  with  the  temperature 
curve,  we  can  follow  the  case  and  interpret  it  from  the  prognostic 
standpoint  with  a  fair  degree  of  safety. 

There  are,  however,  exceptions:  Patients  in  whom  the  disease 
has  been  arrested,  i.  e.,  in  whom  a  quiescent  lesion  is  smouldering, 
are  apt  to  remain  underweight  indefinitely,  though  they  feel  quite 
well  and  are  more  or  less  efficient. 

When  patients  are  progressively  losing  it  is  not  advisable  to  tell 

them   the   extent   of   their   denutrition.     The   discouragement   often 

pulls  them  down  much  further.    Conversely,  it  is  often  obser\'ed  that 

patients  gain  weight  after  changing  their  physician,  entering  a  new 

14 


210     SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

sanatorium,  etc.,  and  thus  gain  a  false  impression  that  they  are  on 
the  road  to  recovery.  But  after  the  novelty  of  the  new  surroundings 
has  worn  off,  the  gain  ceases.  They  may  then  even  lose  progressively, 
and  finally  weigh  less  than  before  admission  to  the  institution.  To 
be  of  favorable  prognostic  significance,  gain  in  weight  must  be  per- 
sistent for  several  months. 

In  some  cases  of  phthisis  the  emaciation  is  rapid  and  extreme, 
within  a  few  months  the  body  of  the  victim  is  reduced  to  a  skeleton. 
These  are  the  cases  in  which  the  disease  runs  an  acute  and  progressive 
course — galloping  consumption.  Now  and  then  we  meet  with  patients 
in  whom  the  disease  is  chronic,  lasting  for  many  years,  still  the  emacia- 
tion is  severe;  the  ribs,  robbed  of  their  adipose  covering,  protrude 
between  the  atrophied  intercostal  muscles  so  that  we  are  unable  to 
adapt  the  bell  of  the  stethoscope  to  the  chest.  This  cachectic  form  of 
phthisis  is  mostly  seen  in  old  people  and,  inasmuch  as  they  have  no 
fever  and  hardly  cough,  latent  cancer  is  at  times  erroneously  diagnos- 
ticated. 

Prognostic  Significance  of  Emaciation. — Sanatoriums  advertising 
their  advantages  usually  show  the  average  number  of  pounds  gained  by 
the  patients  during  a  certain  period,  and  patients  usually  gauge  their 
progress  by  the  scale.  This  is  correct  in  the  vast  majority  of  cases. 
An  improving  patient  is  one  who  gains  in  weight,  and  one  who  loses 
progressively  is  doomed.  But  to  this  there  are  some  exceptions. 
Gains  in  institutions  while  the  patient  is  under  a  rigorous  rest  cure 
and  overfed  for  long  periods  are  good  as  far  as  they  go.  But  in  order 
that  the  patient  should  be  pronounced  improved  or  cured  it  is  neces- 
sary that  he  should  hold  his  gains  after  he  becomes  active  at  his 
occupation  or  at  some  other  vocation  which  suits  him:  In  this  regard, 
the  graduated  labor  system  of  Paterson  at  Fromley  is  superior  to 
other  forms  of  institutional  treatment.  The  gains  attained  at  From- 
ley are  more  lasting  than  those  in  the  institutions  where  the  inmates 
lead  a  lazy  or  indolent  life.  Similarly,  patients  who  are  treated  at 
home  and  allowed  to  do  some  work  while  under  treatment  are  more 
likely  to  keep  their  gains  than  the  former  class. 

We  must  be  careful  in  evaluating  gains  in  weight.  Sometimes  the 
patient  keeps  on  gaining  moderately  while  the  disease  is  progressing 
and  we  wonder  why  this  is  so.  A  careful  investigation  may  show  that 
the  lower  limbs  are  edematous,  and  it  is  not  fat  and  flesh  which  is 
responsible  for  the  increase  in  weight,  but  dropsical  fluid. 

At  times  we  meet  with  patients  in  whom  the  lesion  in  the  lungs  is 
improving  or  stationary  and  they  have  a  good  or  even  a  voracious 
appetite,  yet  they  keep  on  losing  in  weight.  This  is  usually  due  to 
intestinal  tuberculosis  in  which  there  may  not  be  the  characteristic 
diarrhea.  This  is  a  diagnostic  point  worth  remembering  because  it 
is  often  very  difficult  to  decide  whether  the  intestine  is  implicated  in 
the  process,  and  the  prognosis  depends  so  much  on  the  condition  of 
the  bowels. 


EMACIATION  211 

Seasonal  Influences.— The  seasonal  influences  on  the  weight  of 
consumptives  are  best  studied  in  sanatoriums.  It  appears  that  there  are 
significant  differences  in  this  regard.  Minor/  in  Asheville,  reports 
that  the  chief  gains  are  noted  during  the  months  of  October  to  May, 
falhng  off  during  the  summer.  At  North  Reading,  Mass.,  Burns^ 
found  that  the  minimum  amount  of  weight  loss  occurs  in  the  colder 
months;  the  maximum  loss  occurs  in  the  warmer  months;  and  rapid 
increase  in  amount  of  emaciation  appears  during  the  spring  months. 
Going  hand-in-hand  with  this  is  the  fact  that  deaths  in  July  out- 
number all  other  months.  At  the  Adirondack  Cottage  Sanitarium, 
Brown^  found  that  the  weight  curve  in  pulmonary  tuberculosis,  if 
not  influenced  by  change  of  climate  or  some  other  factors,  rises  from 
August  to  Christmas  (sometimes  to  November),  remains  more  or  less 
stationary  with  minor  fluctuations  from  Christmas  to  Easter  (March), 
and  sinks  gradually  from  Easter  to  August.  Brown  adds  that  this 
corresponds  closely  to  the  normal  weight  curve.  Among  private 
patients  in  New  York  City  I  find  that  the  summer  months  are  not 
conducive  to  gains  in  weight,  nor  are  the  autumn  months  with  their 
variable  weather;  but  during  the  winter,  especially  during  very  cold 
seasons,  the  gains  are  extraordinary;  even  patients  who  are  running 
low  from  one  reason  or  another  often  gain  somewhat  or  remain  station- 
ary during  December,  January,  and  February. 

This  is  not  true  of  other  climatic  regions.  In  a  careful  study  of  the 
weights  of  consumptives  in  eight  sanatoriums  in  Denmark,  N.  S., 
Strandgaard^  found  that  weekly  weighing  shows  low  gains  during  the 
winter  and  spring  months  from  December  to  May.  Then  there  is  a 
distinct  rise  during  the  summer  months,  June,  July  and  August,  reach- 
ing its  maximiun  in  September  and  declining  in  October  and  more 
so  in  November  and  reaching  its  minimum  in  December.  This  is  the 
exact  opposite  of  conditions  in  the  United  States. 

The  subject  deserves  ca,reful  study  in  connection  with  meteorological 
conditions. 

Fat  Consumption. — The  term  "fat  consumption"  may  appear 
incongruous,  but  we  meet  with  cases  of  active  phthisis  in  which  the 
panniculus  adiposus  is  well  preserved,  or  even  with  excessive  actual 
obesity,  the  phtisiques  gras  of  French  writers.  I  see  several  cases  of 
this  sort  annually  in  my  private  and  hospital  work.  They  appear 
healthy,  with  rosy  cheeks  and  well-formed  bodies  and  their  only 
trouble  is  that  nobody  believes  that  they  are  tuberculous.  They 
cough  and  expectorate,  often  profusely,  quantities  of  sputum  reeking 
with  tubercle  bacilli,  run  a  mild  subfebrile  temperature,  at  times  have 
nightsweats.  Many  have  more  or  less  profuse  hemoptysis  and  in 
two  that  were  under  my  care  the  cause  of  death  was  copious  terminal 
hemorrhages. 

1  Kleb's  TuVjerculosis,  p.  174.  2  Boston  Med.  and  Surg.  Jour.,  1914,  clxx,  564. 

3  Osier's  Modern  Medicine,  i,  380. 

^Beitr.  z.  klin.  d.  Tuberk.,  1914,  xxxii,  179. 


212    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

When  these  patients  present  themselves  for  examination  one  is 
loath  to  make  a  diagnosis  of  phthisis  even  when  physical  exploration 
of  the  chest  reveals  a  typical  lesion  in  one  or  both  lungs  or  cavitation 
which  is  not  uncommon.  The  course  of  the  disease  is  rather  slow; 
we  may  follow  them  for  years  without  noting  any  marked  changes  in 
their  general  condition  despite  the  fact  that  the  lesion  in  the  lungs  is 
progressing  and  excavations  are  forming.  Of  course,  only  positive 
sputum  findings  are  convincing  in  these  oases. 

The  obesity  is  mostly  seen  in  female  consumptives,  though  I  have 
met  it  in  males,  especially  alcoholics  and  those  having  a  history  of 
syphilis.  They  usually  have  a  voracious  appetite  and  when  told  that 
they  must  eat  well,  they  follow  directions,  often  overdoing  it.  Com- 
bined with  the  rest  which  is  urged,  the  overfeeding  is  effective  in 
producing  fat  despite  the  activity  of  the  disease.  In  tuberculosis 
implanted  on  pulmonary  emphysema,  and  also  in  fibroid  phthisis  the 
weight  of  the  patients  is  often  above  the  average,  though  obesity  is 
observed  only  rarely. 

Fat  consumption  is  also  observed  in  children,  especially  infants  of 
tuberculous  stock.  They  appear  Avell  nourished  and  fat,  but  when 
we  examine  their  muscles  we  find  them  flaccid  and  soft.  These  "pasty" 
infants  have  no  resistance  against  infection  and  are  carried  off  by  any 
acute  disease  which  flares  up  the  dormant  tuberculous  lesions.  Simi- 
larly, tuberculous  meningitis  and  bronchopneumonia  are  often  seen 
in  rather  fat  children. 

THE   SKIN. 

In  addition  to  the  wasting  of  the  muscles  and  subcutaneous  fat, 
atrophy  of  the  skin  is  one  of  the  early  changes  in  phthisis.  Wheaton 
and,  especially,  Pottenger,  have  studied  this  symptom  in  great  detail. 
On  inspection  it  is  noted  that  the  skin  over  the  site  of  the  lesion  is 
thin,  and  the  subcutaneous  tissue  vanished.  According  to  Pottenger, 
this  is  part  and  parcel  of  the  general  degeneration,  and  occurs  after 
the  process  has  existed  for  some  time.  It  denotes  chronicity  rather 
thOiU  earliness,  although  it  is  often  found  over  comparatively  early 
tuberculous  processes.  In  such  cases  it  may  be  presumed  that  there 
was  an  old  quiescent  lesion  which  has  become  the  seat  of  renewed 
activity. 

The  complexion  of  the  consumptive  is  usually  pale,  though  at  times 
we  meet  with  patients  advanced  in  the  disease  who  have  retained 
a  florid  color.  In  some  the  hectic  flush  is  evident  at  first  sight;  it 
is  mostly  seen  at  the  time  when  the  daily  rise  in  temperature  occurs. 
Occasionally  this  redness  appears  only  on  one  cheek,  corresponding 
usually  to  the  affected  side  of  the  lung,  as  is  discussed  elsewhere.  In 
fibroid  phthisis,  and  in  those  with  emphysema,  there  may  be  cyanosis 
of  variable  degree.  In  many  cases  with  extensive  exca\-ations  in  both 
lungs  there  is  hardly  any  cyanosis,  at  most  some  li\'id  tint  of  the 
lips  may  be  elicited  on  careful  obse^^•ation,  but  in  fibroid  phthisis  the 


THE  SKIN  213 

cyanosis  is  frequently  marked.  In  far-advanced  disease  with  amyloid 
changes,  the  skin  shows  the  characteristic  appearance  of  this  condition. 

Cholasma  Phthisicorum. — Smooth,  shining,  and  non-desquamat- 
ing, yellowish-brown  spots  are  occasionally  seen  quite  early  in  the 
disease  on  the  forehead  and  upper  parts  of  the  face.  They  are  fre- 
quently single,  but  often  confluent,  forming  large  patches  which  in 
female  patients  may  be  a  great  source  of  annoyance.  My  experience 
with  consumptives  confirm-s  the  observation  made  long  ago  by  Jean- 
nin  to  the  effect  that  cholasma  phthisicorum  is  mostly  seen  in  con- 
nection with  enlarged  glands  and  that  these  patients  only  rarely  suffer 
from  hemoptysis.  In  fact,  I  have  looked  in  all  cases  of  hemorrhage 
that  have  come  under  my  observation  during  the  past  five  years  and 
found  no  one  with  this  eruption  of  the  skin,  while  among  my  other 
patients  it  is  quite  frequent.  In  advanced  cases  we  often  meet  with 
brownish  coloration  of  the  skin,  mostly  marked  on  the  face,  but  at 
times  all  over  the  body,  simulating  the  smoky  gray  or  bronze  color 
seen  in  Addison's  disease.  Considering  the  frequency  with  which  the 
adrenals  are  found  affected  in  consumptives,  we  have  an  explanation 
for  this  phenomenon. 

Patients  who  sweat  profusely  may  show  miliaria  or  sudamina  on 
the  chest  and  abdomen.  Herpes  zoster  of  the  trunk  and  limbs  may 
also  occur,  mostly  in  patients  with  caries  of  the  spine. 

Pityriasis  Tabescentium. — In  more  or  less  advanced  cases  other 
skin  eruptions  are  often  seen  which  are,  within  certain  limits,  charac- 
teristic of  phthisis.  In  those  who  sweat  profusely  the  atrophied  skin 
is  during  the  day,  dry,  pale  and  brittle,  and  t,he  upper  epidermic  layer 
desquamates  and  sheds  yellow  or  gray  scales.  In  some  cases  it  looks 
as  if  the  skin  was  covered  with  dust.  It  is  known  as  pityriasis  tabes- 
centium and  occurs  mostly  in  consumptives  who  are  not  extremely 
emaciated,  but  who  have  excessive  secretion  of  sweat  and  sebum;  it 
is  localized  over  the  chest  anteriorly  and  posteriorly,  but  at  times 
the  entire  body  is  covered  with  it.  It  may  be  seen  in  other  wasting 
diseases,  but  most  often  in  phthisis. 

Pityriasis  Versicolor. — This  is  even  more  often  seen  in  phthisis. 
The  eruption  is  discretely  scattered  over  the  anterior  and  posterior 
aspects  of  the  thorax  and  consists  of  small  macules,  slightly  raised 
above  the  level  of  the  skin,  round  or  oval  in  shape  with  well-defined 
margins.  Scales  can  be  scratched  off  and  when  examined  show 
roundish,  shining  microscopic  spores,  the  Microsyor on  furfur. 

The  color  of  the  eruption  varies  in  different  individuals,  but  is 
mostly  brown  or  a  dirty  yellow,  darker  in  those  who  lead  an  outdoor 
life,  and  over  the  arms  and  neck  when  these  are  aft'ected,  while  in 
negroes  they  are  almost  white.  In  patients  who  neglect  to  attend  to 
cleanliness  of  their  bodies  the  macules  may  coalesce,  forming  large, 
irregular  plaques  covering  large  tracts  of  skin  anteriorly  and  poste- 
riorly, which  desquamate  upon  scratching. 

It  is  seen  in  consumptives  who  sweat  profusely  at  night,  which 


214    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 

favors  the  growth  of  the  fungi,  and  m  patients  whose  skin  has  a  ten- 
dency to  scale  which  assists  in  their  detachment.  Piery^  has  inoculated 
guinea-pigs  with  the  scales  removed  from  such  patients  and  obtained 
positive  results,  and  he  suggests  that  it  is  a  tuberculous  dermato- 
mycosis. 

When  seen  on  the  chest,  pityriasis  versicolor  is  fairly  indicative  of 
phthisis,  although  it  occurs  in  other  cachectic  diseases,  notably  cancer. 

We  also  meet  with  acnitis  and  folliclis,  characterized  by  the  eruption 
of  red  or  dark  brown  nodules  over  the  face,  and  more  often  over  the 
back  between  the  shoulder-blades  and  over  them.  We  find  these 
nodules  in  various  stages  of  development,  some  becoming  pustular 
and  when  the  pus  is  discharged  an  ulcer  remains,  which  heals,  leaving 
a  scar.  They  are  found  in  exceedingly  chronic  cases.  It  has  been  my 
impression  that  the  administration  of  creosote  and  arsenic  and  their 
derivatives  is  effective  in  enhancing  these  eruptions. 

The  Hair. — Many  authors  have  stated  that  alopecia  is  more  fre- 
quent in  phthisical  subjects  than  in  others,  and  it  has  been  attributed 
to  the  same  causes  as  those  acting  when  the  hair  falls  out  after  an 
attack  of  typhoid  fever,  etc.  But  in  my  experience  this  is  not  true. 
The  tuberculous  patients  in  my  hospital  and  private  practice  are 
not  more  often  bald  than  others  of  the  same  class,  nor  do  I  meet  with 
many  consumptives  who  have  localized  alopecia,  or  alopecia  areata. 
Premature  grayness  of  the  hair,  which  Cornet  mentions  as  very  fre- 
quent among  consumptives,  has  also  not  been  found  by  me  to  be 
frequent  in  tuberculous  patients  in  the  United  States. 

Clubbed  Fingers. — Clubbed  fingers  were  already  mentioned  by 
Hippocrates  as  a  symptom  of  phthisis,  and  French  writers  at  present 
call  them  doigts  hippocratiques.  They  are  found  in  about  one-third 
of  advanced  consumptives,  and  are  probably  caused  by  chronic  per- 
ipheral passive  congestion.  Clubbed  fingers  are  not  exclusively  met 
with  in  phthisis,  but  also  in  empyema,  bronchiectasis,  chronic  bron- 
chitis, asthma  and  pulmonary  emphysema,  in  thoracic  aneurisms, 
etc.  They  have  also  been  encountered  in  rare  cases  of  cirrhosis  of 
the  liver  and  amyloid  disease. 

In  phthisis  we  usually  find  that  the  fingers  of  both  hands  are 
thickened  and  bulbous,  like  a  club  or  drumstick,  resembling  somewhat 
the  condition  seen  in  chronic  onychia.  The  terminal  phalanges  are 
enlarged,  the  nails  curved  longitudinally  and  laterally.  From  radio- 
scopic  studies  it  appears  that  the  bones  and  joints  are  not  aftected, 
nor  is  the  skin  altered  in  any  way,  but  only  the  superficial  soft  parts 
are  hypertrophied.  As  to  what  the  change  consists  in  we  are  in 
ignorance  because  of  lack  of  anatomical  and  histological  studies. 
Some  have  suggested  that  it  is  a  fibrous  thickening  of  the  innermost 
layers  of  the  epidermis,  as  a  result  of  prolonged  congestion  of  the 
capillaries.    This  may  be  true  of  some  cases,  but  in  those  in  which 

1  Gaz.  d.  hopit,  1912,  Ixxxv,  531. 


THE  SKIN  215 

the  condition  develops  within  a  few  weeks  it  is  doubtful  whether  this 
could  be  the  actual  anatomical  change. 

In  most  cases  the  onset  is  slow  and  insidious  and  the  patient  knows 
nothing  about  it  till  the  physician  calls  his  attention  to  the  clubbed 


Fig.  32. — Clubbed  fingers  and  curved  nails. 

fingers.  But  on  rare  occasions,  as  has  already  been  noted  by  Trous- 
seau, it  comes  on  very  quickly  and  within  a  few  weeks  the  fingers  look 
like  drumsticks.  In  these  acute  cases  they  may  be  painful,  tender 
and  livid.  Lividity  is  also  seen  in  those  suffering  from  pulmonary 
emphysema  or  fibroid  phthisis.  The  nails  are  curved  and  look  like 
claws. 


Fig.  33. — Clubbed  fingers  in  phthisis. 

My  observations  are  in  agreement  with  those  of  Bezanyon^  that 
clubbed  fingers  are  not  met  with  in  all  cases  of  chronic  phthisis,  as 

lArch.  gen.  de  Medecine,  1904,  i,  1663;   ii,  3100. 


216    SYMPTOMS  REFERABLE  TO  GASTRO-INTESTINAL  TRACT 


Fig.  34. — Changes  in  the  toes  in  tuberculous  osteo-arthropathy. 


Fig.  3.5. — Radiogram  of  a  hand  in  a  case  of  clubbed  fingers  in  pulmonary  osteo- 
arthropathy with  bronchiectasis  and  pulmonary  emphysema.  On  the  tijis  of  the  end 
phalanges  marked  cauliflower  formations;  bony  excrescences  on  basal  portions  of  some 
phalanges;    typical  Heberden's  nodes;    broadening  of  the  bases  of  the  middle  phalanges. 


THE  SKIN 


217 


some  have  stated.  A  large  number  of  consumptives  have  normal- 
shaped  fingers,  while  some  have  even  long,  tapering  terminal  phalanges. 
Clubbed  fingers  are  encountered  almost  exclusively  in  fibroid  phthisis, 
pulmonary  emphysema  with  tuberculosis  and  in  those  having  exten- 
sive pleural  adhesions.  In  other  words,  whenever  clubbed  fingers 
are  encountered  in  a  case  of  phthisis  we  find  that  the  patient  is  also 
sufl'ering  from  dyspnea  and  dilatation  of  the  right  heart.  This  would 
suggest  mechanical  disturbances  of  the  circulation,  causing  peripheral 


Fig.  36. — Radiograms  of  hand  in  a  case  of  fibroid  phthisis. 


venous  stasis.  Moreover,  the  prognosis  in  these  cases  is  quite  favor- 
able as  regards  duration  of  life,  though  the  outlook  as  to  comfort  is 
rather  gloomy. 

Pulmonary  Osteo-arthropathy. — In  some  chronic  cases  we  meet 
with  enlarged  hands  simulating  those  seen  in  acromegaly.  The 
fingers  are  altogether  increased  in  volume,  the  nails  enlarged  and 
curved  like  the  beak  of  a  parrot.  The  metacarpophalangeal  region 
is  usually  normal,  but  the  wrist  is  enlarged  and  deformed,  bulging  on 
its  dorsal  aspect.  In  many  cases  there  is  also  some  deformity  of  the 
spine — kyphoscoliosis,  and  the  feet  may  show  the  same  changes  as 
the  wrists  and  hands,  especially  the  toes  and  tarsus.     In  the  cases 


218    SYMPTOMS  REFERABLE  TO  G ASTRO-INTESTINAL  TRACT 

that  came  under  my  observation  there  were  pains  of  \'ariable  severity, 
sometimes  unbearable  and  generally  intermittent.  As  can  be  seen  from 
the  radiograms  (Figs.  35  and  36)  the  differences  between  pulmonary 
osteo-arthropathy  and  simple  clubbed  fingers  consists  in  this:  In  the 
former  the  bones  and  joints  are  hypertrophied  and  some  osteophytes 
may  be  seen  at  the  line  of  the  joint  cartilages,  while  in  the  latter  only 
the  soft  parts  are  implicated,  the  bones  remaining  practically  normal. 
In  his  recent  thorough  study  of  this  subject,  Edwin  A.  Locke^  is 
inclined  to  regard  clubbed  fingers  in  phthisical  patients  as  identical 
with  osteo-arthropathy,  the  former  representing  an  early  stage  of  the 
latter.  He  also  found  with  clubbed  fingers  early  proliferative  changes 
in  the  periosteum  of  some  of  the  long  bones  of  the  forearm  and  lower 
legs  of  exactly  the  same  type  as  in  hypertrophic  osteo-arthropathy. 
Clinically  we  distinguish  these  two  conditions  by  the  fact  that  in 
clubbed  fingers  only  the  terminal  phalanges  are  enlarged,  while  in 
osteo-arthropathy  the  wrist  is  also  affected,  and  the  feet  usually  show 
the  same  changes  and  in  addition  there  is  in  most  cases  decided  spinal 
deformity.  But  this  does  not  exclude  the  identity  of  the  two  processes 
if  we  choose  to  regard  clubbed  fingers  as  the  early  stage  of  osteo- 
arthropathy.    The  former  is,  however,  far  more  common. 

1  Archives  of  Internal  Medicine,  1915,  xv,  659. 


CHAPTER  XII. 

SYMPTOMS  REFERABLE  TO  THE  CARDIOVASCULAR 
AND  RENAL  SYSTEMS. 

THE    CARDIOVASCULAR    SYSTEM. 

Cardiac  Palpitation. — Of  the  functional  cardiovascular  disturbances 
in  phthisis  the  most  important  are  palpitation,  tachycardia,  and  hypo- 
tension. They  are  very  often  associated,  but  at  times  we  meet  one  to 
the  exclusion  of  the  other. 

In  incipient  cases  palpitation  is  mainly  met  with  in  young  persons, 
especially  chlorotic  girls.  Slight  or  moderate  exertion,  excitement  and 
emotional  disturbances  may  cause  an  attack,  or  it  may  occur  without 
any  provocation.  At  times  it  is  very  pronounced,  and  is  perhaps  the 
only  subjective  symptom  which  induced  the  patient  to  consult  a 
physician.  Rarely  it  is  very  severe  and  is  accompanied  by  precordial 
pains  and  distress  and  by  vasomotor  disturbances  such  as  pallor  or 
flushing  of  the  face,  sweating,  etc. 

I  have  met  with  cases  in  which  palpitation  preceded  all  subjective 
and  objective  symptoms  of  incipient  phthisis.  Some  are  for  this  reason 
treated  for  heart  disease.  Recently  I  saw  a  case  which  was  treated 
for  hyperthyroidism,  but  careful  examination  showed  an  incipient 
lesion  of  the  left  apex. 

The  causes  of  the  palpitation  at  this  stage  are  not  clear.  Some  have 
been  inclined  to  attribute  it  to  dilatation  of  the  right  heart,  but  we 
meet  it  in  cases  in  which  this  organ  is  normal.  Others  believe  it  is 
due  to  the  anemia — low  arterial  tension — or  to  sympathetic  nerve 
disturbances.  The  last  factor  is  apparently  operative  in  many  cases, 
because  we  meet  it  mostly  in  nervous  patients,  in  young  girls  and  in 
women  during  the  menopause.  Compression  of  the  vagus  by  enlarged 
glands  may  be  the  cause  in  some  cases. 

Cardiac  irritability  is  seen  also  in  advanced  but  quiescent  cases. 
The  patient  is  doing  well,  has  no  fever,  no  cough  and  is  not  emaciated. 
But  the  least  exertion,  emotion,  or  complication  provokes  cardiac  dis- 
tress which  may  be  very  painful,  almost  anginal.  Here,  the  palpita- 
tion is  due  to  cardiac  dislocation  and  occurs  more  often  in  left-sided 
lesions.  A  large  cavity  in  the  left  lung  with  pulmonary  contraction 
has  drawn  the  mediastinum  to  the  left  and  the  diaphragm  upward, 
so  that  the  heart  is  pushed  upward  and  to  the  left  and  the  apex  beat 
may  be  found  in  the  third  interspace  at  the  axillary  line.  In  a  recent 
case  of  this  character  I  also  found  arrhythmia.    The  palpitation  is  not 


220    SYMPTOMS  REFERABLE  TO  CARDIOVASCULAR  SYSTEM 

so  pronounced  in  right-sided  dislocations  of  the  heart,  not  even  in 
complete  dextrocardia. 

Palpitation  has  no  influence  on  the  course  of  phthisis  excepting 
in  the  advanced  stages  when  it  is  due  to  dislocation  of  the  heart. 
In  the  early  cases  we  may  meet  with  annoying  palpitation  in  nervous 
patients  who  are  progressively  improving.  But  from  the  diagnostic 
standpoint  it  is  a  symptom  of  great  value.  Hirtz  said  that  "when  a 
patient  complains  of  palpitation,  examine  his  lungs;  and  examine 
his  heart  when  he  complains  of  dyspnea."  While  this  does  not  hold 
good  in  every  case,  yet  it  is  well  worth  bearing  in  mind,  especially 
when  dealing  with  an  anemic  youth.  In  some  cases  of  phthisis  we 
meet  with  palpitation  for  a  day  or  two  before  the  occurrence  of 
hemoptysis. 

Tachycardia. — Rapid  heart  action  objectively  ascertained — which 
may  not  be  known  to  the  patient  at  all,  thus  differing  from  palpitation, 
which  is  a  subjective  symptom — is  very  frequent  in  all  stages  of 
phthisis.  In  my  experience,  over  80  per  cent,  of  cases  of  incipient 
phthisis  have  tachycardia  which  is  usually  permanent  or,  rarely,  par- 
oxysmal. It  is  a  symptom  of  phthisis  which  is  not  appreciated  to  the 
extent  it  deserves,  though  it  is  often  very  helpful  in  deciding  a  doubt- 
ful case. 

The  tachycardia  may  be  of  toxic  origin.  Every  elevation  of  tem- 
perature in  phthisis,  as  in  other  conditions,  is  accompanied  by  an 
acceleration  in  the  pulse  rate.  But  it  is  often  pronounced  in  those 
running  a  subfebrile  temperature  and  also  in  afebrile  cases.  In  fact, 
in  tuberculosis  the  pulse  is  accelerated  far  out  of  proportion  to  the 
height  of  the  temperature.  In  most  other  cases  ati  elevation  of  1°  F. 
is  usually  accompanied  by  an  increase  in  the  pulse  rate  of  about 
eight  beats  per  minute,  while  in  phthisis  we  often  have  a  temperature 
of  100°  while  the  pulse  counts  120  and  even  more.  In  fact,  in  most 
afebrile  cases  of  phthisis  the  pulse  is  over  90  per  minute  and  during 
the  morning  subnormal  temperature  tachycardia  is  not  at  all  rare. 
Thus  tachycardia  is  an  early  symptom  of  phthisis  and  some  writers 
consider  it  a  premonitory  symptom. 

Permanent  Tachycardia. — In  a  large  proportion  of  cases  the  tachy- 
cardia is  permanent  and  accompanied  by  subjective  discomfort,  such 
as  palpitation,  languor,  debility,  dyspnea,  etc.  In  others,  it  is  purely 
objective,  the  patient  is  hardly  aware  of  its  presence.  I  have  observed 
many  cases  in  which  the  disease  was  arrested  or  even  cured,  yet  the 
tachycardia  remained.  At  times  it  greatly  interferes  with  the  patient's 
efficiency.  But  I  cannot  agree  with  Minor  who  says  that  in  an  arrested 
case  one  cannot  feel  safe  as  to  the  continued  progress  of  the  patient  so 
long  as  the  pulse  rate  remains  high.  I  have  seen  patients  who  have 
been  able  to  work  for  a  living  without  much  discomfort  in  spite  of  the 
rapid  heart  action. 

One  characteristic  of  the  pulse  of  the  consumptive  is  its  instability 
and  variability.     While  resting  the  rate  may  be  normal,  but  the 


THE  CARDIOVASCULAR  SYSTEM  221 

slightest  exertion — a  fit  of  coughing,  some  emotional  experience,  a 
heavy  meal,  or  changing  from  the  reclining  to  the  erect  posture — ^may 
send  up  the  pulse  rate  to  110  or  120,  though  Wells  says  the  contrary 
and  Minor  found  it  present  as  often  as  absent ;  Faisans  says  that  he 
does  not  know  of  any  disease  in  which  the  pulse  is  as  unstable  as  in 
phthisis. 

Paroxysmal  Tachycardia. — In  rare  cases  we  meet  with  paroxysmal 
tachycardia.  The  patient  feels  comparatively  well  and,  without  any 
exciting  cause,  he  is  seized  with  severe  palpitation,  dyspnea,  or  even 
orthopnea,  and  cyanosis.  Counting  the  pulse  rate,  we  find  it  150  to 
200  per  minute,  small,  wiry  and  often  irregular.  The  attack  may 
last  a  few  hours,  a  day  or  two.  In  one  case  the  patient  got  an  attack 
while  in  my  office,  the  pulse  going  up  from  96  to  160,  and  looked  as  if 
he  was  breathing  his  last.    He  recovered  in  two  hours. 

After  several  attacks,  which  may  come  on  at  frequent  intervals, 
we  may  observe  signs  of  cardiac  dilatation — the  heart  gives  way  and 
the  result  is  edema  of  the  lower  extremities,  enlargement  of  the  liver, 
etc.  Finally,  asystole  occurs  and  the  patient  succumbs.  Paroxysmal 
tachycardia  is  of  grave  significance  and,  when  occurring  several  times, 
will  ultimately  kill  the  patient  during  one  of  the  attacks. 

Causes  of  Tachycardia. — The  causes  are  obscure.  It  has  been 
attributed  to  bulbar  lesions,  to  interstitial  neuritis  of  the  pneumo- 
gastric  nerve  and  to  myocarditis,  etc.  Some  believe  that  it  is  due 
to  compression  of  the  vagus  by  enlarged  tracheobronchial  glands, 
but  it  would  seem  that  the  effect  should  rather  be  a  slowing  of  the 
pulse  rate  than  an  acceleration.  Indeed,  considering  that  the  vagus 
is  often  pressed  upon  by  enlarged  glands,  it  is  noteworthy  that  a  slow 
pulse  is  exceedingly  rare  in  phthisis.  Other  authors  have  attempted 
to  explain  this  phenomenon  by  stating  that  it  all  depends  on  which 
part  or  branch  of  the  pneumogastric  is  affected  by  the  tuberculous 
process.  On  this  also  depends  whether  the  stomach  or  myocardium 
will  suffer.  K.  Bohland^  is  inclined  to  ascribe  the  tachycardia  in 
phthisis  to  the  small  heart  characteristic  of  the  disease — in  order  to 
pump  enough  blood  into  the  system,  the  heart  must  beat  more  often. 
In  the  advanced  stages  of  phthisis  it  is  due  to  myocarditis.  The 
tuberculous  toxemia  alone  does  not  explain  the  tachycardia  because 
it  is  found  often  in  afebrile  patients,  as  was  already  stated. 

Permanent  tachycardia  aggravates  the  prognosis  of  phthisis  and 
these  patients  should  not  be  sent  to  a  high  altitude.  The  causes  are 
complex  and  vary  with  each  case.  In  patients  in  whom  it  is  of  toxic 
origin  we  may  expect  improvement  as  soon  as  the  fever  subsides.  But 
in  many  it  is  caused  by  compression  of  the  pneumogastric  nerve  by 
enlarged  tracheobronchial  glands,  neuritis  of  that  nerve,  or  reflexly  of 
gastric  origin,  fibrous  degeneration  of  the  cardiac  muscle,  or  tubercu- 
losis or  hyperf unction  of  the  adrenals,  etc.  When  due  to  cardiac 
displacement,  especially  to  the  left  in  left-sided  lesions,  it  is  permanent, 

1  Brauor,  Schroder,  and  Blumenfeld's  Handbuch  der  Tuberkulose,  1915,  iv,  4. 


222     SYMPTOMS  REFERABLE  TO  CARDIOVASCULAR  SYSTEM 

Arrhythmia  is  only  rarely  observed  in  phthisis  and  the  prognosis  of 
these  cases  is  rather  unfavorable. 

Bradycardia. — A  slow  pulse  is  exceedingly  rare  in  phthisis;  those 
who  see  large  numbers  of  these  patients  occasionally  meet  one  with 
a  pulse  less  than  50  per  minute.  One  case  under  my  care  had  a 
pulse  rate  of  36  per  minute  for  several  months,  and  only  dining  febrile 
attacks  did  it  rise  to  50  or  slightly  more.  Gueneau  de  Mussy,  who 
described  some  of  these  cases,  attributed  it  to  irritation  of  the  pneu- 
mogastric  nerve.  On  the  other  hand,  there  are  many  physicians  of 
large  experience  who  have  never  seen  bradycardia  in  phthisis.  From 
the  few  cases  met  b}^  me,  it  appears  that  the  prognosis  in  cases  with 
a  slow  pulse  is  very  good.  "A  slow  pulse  when  met  with  is  always  of 
good  augury,"  says  Sir  Douglas  Powell,^  "and  in  some  obscure  and 
borderline  cases  it  would  tell  with  considerable  force  in  favor  of  the 
case  not  being  one  of  tuberculosis." 

At  the  terminal  stage  of  far-advanced  phthisis  we  often  meet  with 
a  slow,  soft,  almost  imperceptible  pulse  which  intermits,  indicating 
cardiac  failure  or  exhaustion.  The  pulse  is  also  slowed  when  meningeal 
irritation  complicates  the  disease. 

Arterial  Hypotension. — The  blood-pressm-e,  measured  with  a 
sphygmomanometer,  is  lower  than  normal  in  the  vast  majority  of 
phthisical  patients.  It  is  evidently  due  to  the  toxic  effects  of  the 
metabolic  processes  of  the  tubercle  bacilli,  because  an  injection  of 
tuberculin  is  usually  followed  by  a  decided  fall  in  the  blood-pressure. 
Sir  Douglas  Powell  says  that  the  large  doses  of  tuberculin  which  were 
used  in  the  first  days  of  Koch  treatment  of  lupoid  and  other  forms  of 
tuberculosis  caused  severe  collapse,  and  recent  ^Titers,  like  Levy, 
Geisbock  and  others  found  that,  even  in  small  or  moderate  doses, 
tuberculin  reduces  arterial  tension.  It  has  been  found  that  a  low 
blood-pressure  is  an  almost  constant  characteristic  of  the  very  early 
stages  of  phthisis  and,  when  occurring  in  an  adult  without  any  other 
assignable  cause,  tuberculosis  is  to  be  suspected.  John  Ritter-  found 
hypotension  in  cases  of  phthisis  before  the  physical  signs  and  even 
before  elevation  of  temperature  were  definitely  demonstrable.  My 
own  experience  has  brought  me  to  the  conclusion  that  in  cases  pre- 
senting obscure  symptoms  and  signs  of  phthisis,  when  accompanied 
by  a  low  blood-pressure,  the  diagnosis  may  be  safely  made;  conversely, 
I  always  hesitate  in  cases  with  high  arterial  tension,  excepting  in 
persons  over  fifty  years  of  age.  But  even  in  these  high  pressure  is 
exceedingly  rare  in  phthisis. 

Sir  Douglas  Powell  showed  that  slight  exercise  raises  the  blood- 
pressure  in  quiescent  cases,  while  in  acute  cases  it  is  lowered  (Figs.  37 
and  38). 

This  hypotension  is  (|uite  marked  in  the  early  stages  and  becomes 
more  accentuated  with  the  progress  of  the  disease.     I  find  that,  as 

'  Lancet,  November  23,  1912,  p.  1415. 

2  Trans.  Nat.  Assn.  Study  and  Prev.  Tuber.,  I'JU,  vii,  297. 


THE  CARDIOVASCULAR  SYSTEM 


223 


a  rule,  cases  of  undoubted  phthisis  with  a  normal  or  high  blood-press- 
ure have  a  favorable  prognosis.  When  the  blood-pressure  is  low  at 
first  but  rises  gradually,  it  is  an  excellent  indication  of  improvement; 
conversely,  tuberculous  patients  with  normal  or  high  blood-pressure 
who  begin  to  show  hypotension  almost  invariably  also  show  indica- 


"8  S 

°:  3 

m  0. 
140 

130 

120 

110 

100 

90 

80 

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99 
98 
97 

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Fig.  .37. — Chart  of  blood-pressure  in  a  case  of  quiescent  tuberculosis  before  and 
after  exercise.  Blood-pressure,  * — ■ — ■  (A,  before  exercise;  B,  after  exercise).  Pulse 
rate,  O-  ■  •  .     Temperature,  x .     (R.  Douglas  Powell.) 

tions  of  the  extension  of  the  process  in  the  lung  and  the  prognosis  is 
aggravated.  I  have  not  noted  in  many  cases  any  relation  between 
the  hypotension  of  phthisis  and  the  temperature,  the  pulse  rate,  or 
the  dyspnea.  It  is  met  with  in  febrile  and  afebrile  cases ;  in  young  and 
in  the  aged. 


HO 
130 
120 
110 
100 
90 
80 

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Fig.  38. — Chart  of  blood-pressure  in  tuberculosis  before  and  after  exercise.     Blood- 
pressure,  • (A,  before  exercise;  B,  after  exercise).    Pulse  rate,  O  .  .  .  .    Temperature, 

X .     (R.  Douglas  Powell.) 


It  has  also  been  observed  by  many  authors  that  patients  with  a 
tendency  to  hemoptysis  have  a  high  blood-pressure  which  rises  before 
the  onset  of  the  bleeding.  At  one  time  I  tested  this  point  in  several 
patients  but  could  not  confirm  it.  Many  who  bled  profusely  had  a 
very  low  blood-pressure. 


224    SYMPTOMS  REFERABLE   TO   CARDIOVASCULAR  SYSTEM 

THE   BLOOD. 

The  Erythrocytes. — Despite  the  external  appearance  of  anemia 
frequently  seen  in  many  phthisical  patients  in  all  stages  of  the  disease 
— which  has  given  rise  to  the  expression  "'great  white  plague" — no 
changes  in  the  cytology  of  the  blood  characteristic  of  the  disease  have 
been  found.  In  fact,  it  is  noteworthy  that  many  patients  who  look 
pale  show  an  almost  normal  blood  picture.  At  times  a  polycythemia  is 
encountered,  but  the  hemoglobin  is  not  increased  under  the  circum- 
stances. Only  on  rare  occasions  have  I  found  a  decided  decrease  in 
the  number  of  erythrocytes,  especially  during  the  very  early  and 
very  advanced  stages  of  the  disease.  In  some  few  cases  the  count  was 
as  low  as  1,000,000,  or  even  less,  but  the  fact  that  it  is  so  rare  shows 
that  it  is  an  accidental  occurrence  and  cannot  be  considered  char- 
acteristic of  the  disease.  After  profuse  pulmonary  hemorrhages  the 
anemia  may  be  profound,  but  it  is  remarkable  that  the  blood  improves 
very  rapidly  after  the  cessation  of  bleeding. 

There  is  very  often  noted  a  decidedly  low  percentage  of  hemoglobin 
in  incipient  cases,  even  when  the  erythrocytes  are  not  decreased  in 
number.  For  this  reason  some  authors  have  spoken  of  a  pseudo- 
chlorotic  blood  picture.  But  soon  after  the  patient  is  placed  under 
proper  dietetic  and  hygienic  treatment  the  hemoglobin  content  of 
the  blood  improves,  as  a  rule.  It  may  be  stated  that  in  many  cases 
there  is  slight  diminution  in  the  number  of  erythrocytes,  and  a  pro- 
nounced diminution  in  the  hemoglobin  content  during  the  incipient 
and  far-advanced  stages  of  phthisis. 

From  the  researches  of  Limbeck,  Grawitz,  and  others  it  appears 
that  with  the  advance  of  the  disease,  even  with  the  formation  of 
pulmonary  excavations,  the  blood  picture  is  very  often  not  deviating 
from  the  normal.  The  yellowish  pallor,  "ochrodermia,"  which  is  so 
frequent  at  this  stage,  is  not  due  to  alterations  in  the  cytology  of  the 
blood,  so  far  as  can  be  ascertained.  But  there  is  good  reason  to  believe 
that  the  total  amount  of  blood  in  the  body  is  less  than  in  healthy 
individuals;  that  there  is  a  distinct  oligemia.  This  has  been  ascribed 
to  the  loss  of  water  through  profuse  nightsweats,  expectoration,  and 
often  diarrhea,  which  brings  about  a  higher  specific  gravity  of  the 
blood  with  a  concentration  of  the  cells. 

In  the  far-advanced  stages,  with  hectic  fever,  often  complicated 
by  mixed  infection,  there  is  in  addition  to  leukocytosis,  also  a  diminu- 
tion in  the  number  of  erythrocytes,  with  a  fall  in  the  percentage  of 
hemoglobin. 

Leukocytes. — In  incipient  phthisis  the  leukocytes  are  quite  normal 
in  number  and  variety.  Even  in  acute  cases,  so  long  as  there  is  no 
mixed  infection,  the  leukocyte  count  is  unaffected.  Some  authors, 
notably  Ullom  and  Craig^  in  this  country,  have  found  a  slight  leuko- 

lAmer.  Jour.  Med.  Sci.,  1905,  cxxx,  386. 


THE  BLOOD  225 

cytosis  which  increases  somewhat  with  the  advance  of  the  disease. 
But  inasmuch  as  it  only  reaches  about  11,000  to  14,000  on  the  average, 
it  cannot  be  considered  of  any  value  diagnostically.  Kjer-Petersen^ 
found  that  in  women  the  number  of  white-blood  cells  oscillates  between 
4000  and  25,000  under  normal  physiological  conditions. 

Gerald  B.  Webb,  G.  B.  Gilbert,*  and  L.  C.  Haven^  found  the  blood 
platelets  are  increased  in  number  in  cases  of  phthisis.  In  tuberculosis 
in  guinea-pigs  they  observed  the  same  phenomenon.  They  believe 
that  the  blood  platelets  either  contain  or  supply  opsonins.  The  fact 
that  they  are  increased  at  an  altitude  of  6000  feet  would,  according 
to  Webb,  point  to  a  reason  for  the  salutary  effects  of  high  climates 
on  phthisical  patients. 

With  the  advance  of  the  disease  leukocytosis  is  not  rare;  it  is  usually 
transient,  but  rarely  permanent.  It  appears  to  depend  on  the  activity 
of  the  tuberculous  process,  the  intensity  of  the  fever,  the  presence  of 
complications,  etc.  But  there  are  so  many  exceptions  to  this  rule 
that  it  cannot  be  utilized  for  diagnostic  and  prognostic  purposes.  It 
appears,  however,  that  an  injection  of  tuberculin  is  usually  followed  by 
transient  leukocytosis.  Some  have  attempted  to  judge  the  presence 
of  excavation  by  the  white-cell  picture,  but  have  failed.  Wright's 
attempt  to  utilize  his  tuberculo-opsonic  index  in  the  prognosis  of 
tuberculosis  has  also  failed  to  give  satisfaction  to  most  authors. 

Arneth's  Blood  Picture. — A  great  deal  has  been  made  during  recent 
years  of  Arneth's  blood  work  in  infectious  diseases,  especially  tuber- 
culosis. His  theory  is  based  on  his  observations  of  the  growth  of  the 
neutrophile  and  the  changes  of  the  nuclei,  or  granules  within  these 
cells  during  the  period.  He  developed  a  very  comphcated  blood  picture 
based  on  the  number  of  granules  or  fragments  in  each  neutrophile. 
His  contention  is  that  when  the  disease  takes  a  bad  turn  there  is  an 
increase  in  the  number  of  young  forms  of  neutrophiles  containing  but 
one  granule  as  a  nucleus,  and  a  decrease  in  the  older  forms  of  cells 
which  correspond  to  the  polymorphonuclears  of  other  writers;  he 
calls  it  a  shifting  of  the  blood  picture  to  the  left. 

Arneth's  work  has  been  tested  by  many  other  authors  and  but  very 
few  have  been  able  to  confirm  his  contentions  that  the  changes  in  the 
blood  picture  go  hand-in-hand  with  the  clinical  course  of  the  disease, 
nor  have  many  agreed  with  his  interpretation  of  the  origin  of  the 
changes  in  the  neutrophiles.  In  this  country  some  authors  have  found 
Arneth's  blood  picture  of  value  in  diagnosis  and  prognosis,  especially 
Minor  and  Ringer,^  and  James  Alexander  Miller  and  Margaret  A. 
Reed.*  Miller,  in  an  exhaustive  study  of  the  leukocytes  in  tubercu- 
losis, arrives  at  the  conclusion  that  it  gives  valuable  information  as  to 
the  prognosis  and  clinical  course  of  phthisis,  but  in  the  diagnosis  of 

1  Braucr's  Beitrage,  1906,  Beiheft. 

2  Arch.  Intern.  Medicine,  1914,  xiv,  743. 

3  Amer.  Jour.  Med.  Sci.,  1911,  cxli,  638. 
*  Arch.  Intern.  Med.,  1912,  ix,  609. 

15 


226     SYMPTOMS  REFERABLE  TO  CARDIOVASCULAR  SYSTEM 

incipient  cases  it  is  of  no  value.  In  his  experience  a  leukocytosis,  an 
increased  percentage  of  small  lymphocytes,  a  diminished  percentage 
of  eosinophiles  and  a  marked  shifting  of  Arneth's  blood  picture  to  the 
left  are  characteristic  of  cases  of  pulmonary  tuberculosis  which  are 
progressively  doing  badly,  or  an  exacerbation  of  the  disease. 

I  have  given  this  method  a  trial  and  could  find  no  diagnostic  or 
prognostic  hints  which  were  constant;  in  fact,  the  contradictions 
were  so  frequent  and  notorious  that  I  have  abandoned  it  altogether. 
Pappenheim,  Politzer,  Hiller,  and,  in  this  country,  Solis  Cohen,i  and 
Strickler  and  Kagan-  have  arrived  at  the  same  conclusion. 

Tubercle  Bacilli  in  the  Circulating  Blood. — During  recent  years 
many  investigators  have  found  tubercle  bacilli  in  the  circulating  blood 
of  patients  suffering  from  phthisis.  Some  have  found  them  in  the 
blood  of  patients  with  advanced  forms  of  the  disease,  while  others 
have  even  detected  them  in  early  cases.  Rosenberger,^  Koslow, 
Kurashige,  and  others  have  even  stated  that  in  all  cases  of  tubercu- 
losis, bacilli  may  be  found  when  carefully  looked  for,  while  P.  Klem- 
perer  found  them  in  7  cases  in  which  the  disease  was  only  suspected, 
but  could  not  be  diagnosticated  with  the  usual  clinical  methods. 
But  when  still  others,  like  Liebermeister,  Suzuki  and  Takaki,  and 
Kurashige  discovered  tubercle  bacilli  in  the  blood  of  apparently 
healthy  individuals,  and  Clara  Kennerknecht  in  the  blood  of  91  per 
cent,  of  120  healthy  children  of  which  only  68  were  tuberculous,  the 
hopes  entertained  that  we  might  have  in  this  a  good  method  of  dis- 
covering tuberculosis  as  a  bacteremia  before  the  onset  of  clinical 
symptoms  began  to  vanish.  The  history  of  tuberculin  as  a  diagnostic 
agent  was  here  repeated. 

Further  investigations  by  Walter  V.  Brehm,*  Beitzke,  Schern  and 
Dold  have  shown  that  there  was  a  source  of  error:  The  tap  water 
used  in  diluting  the  blood  often  contains  acid-alcohol-fast  rods  which 
look  like  tubercle  bacilli  under  the  microscope.  These  acid-fast  rods 
may  be  bacilli  or  some  other  substances,  but  they  are  not  pathogenic 
to  guinea-pigs.  It  has  also  been  found  that  fragments  of  red-blood 
corpuscles  may  take  on  the  stain  of  the  tubercle  bacillus  and  show 
acid-fast  properties. 

These  findings  were  verified  in  another  way.  The  blood  of  tubercu- 
lous patients  was  injected  into  animals  with  a  view  of  ascertaining  the 
proportion  that  would  be  infected  with  tuberculosis.  The  results  of 
some  authors  like  Anderson,^  Rumpf,''  Ravenel  and  Smith,^  Querner,^ 


1  New  York  Med.  Jour.,  1910,  xcii,  248. 

2  Boston  Med.  and  Surg.  Jour.,  1910,  clxii,  709. 
•■*  Amer.  Jour.  Med.  Sei.,  1909,  cxxxvii,  2fi7. 

"  Jour.  Amer.  Med.  Assn.,  1909,  liii,  909. 

^  The  Presence  of  Tubercle  Bacilli  in  the  Blood  in  Clinical  and  Experimental  Tuber- 
culosis, Hygienic  Labor.  Bull.,  No.  .57,  1909. 
<>Muneh.  med.  Wehnschr.,  1912,  Hx,  1951. 
^  Jour.  Amer.  Med.  Assn.,  1909,  liii,  1915. 
8  Munch,  med.  Wehnschr.,  1913,  Ix,  401. 


THE  RENAL  SYSTEM  227 

Leo  Kessel/  and  others  were  entirely  negative — none  of  the  animals 
experimented  on  showed  any  tuberculous  lesions,  while  others 
got  a  few  positive  results.  Liebermeister,  on  the  other  hand,  found 
that  in  6  cases  the  animals  were  infected  with  tubercle  bacilli  in 
the  blood  from  human  beings  who  showed  no  clinical  symptoms  of 
the  disease.  Others,  like  Kessel,  found  that  a  few  of  the  animals 
inoculated  with  blood  from  tuberculous  patients  became  tuberculous. 

It  was  necessary  to  explain  the  presence  in  the  blood  of  many  cases 
of  phthisis  of  bacilli,  which  are  but  rarely  pathogenic  to  animals.  It 
was  suggested  that  while  inoculating  the  animals  with  the  blood,  anti- 
bodies are  also  inoculated,  or  that  the  germs  circulating  in  the  blood 
lose  their  virulence  owing  to  the  bactericidal  action  of  the  blood. 

At  the  present  state  of  our  knowledge  the  following  conclusions 
of  Klemperer^  are  justified: 

Acid-fast  rods  are  found  microscopically  in  small  numbers  in  the 
blood  of  a  large  proportion  of  consumptives.  Animal  experimentation 
shows  that  but  few  patients  have  virulent  tubercle  bacilli  in  their 
blood.  But  it  must  be  mentioned  in  this  connection  that  in  order  to 
infect  a  guinea-pig  a  certain  number  of  tubercle  bacilli  is  necessary, 
having  a  certain  virulence,  perhaps  greater  virulence  than  the  bacilli 
that  survive  the  bactericidal  action  of  the  blood  of  the  average  patient 
possesses.  Negative  outcome  of  the  inoculation,  for  this  reason,  does 
not  mean  absence  of  the  bacilli  from  the  blood.  Inasmuch  as  the  acid- 
fast  rods  are  found  microscopically  only  in  the  blood  of  tuberculous 
and  not  of  healthy  persons,  the  negative  outcome  does  not  speak 
against  their  being  tubercle  bacilli.  Finally,  inasmuch  as  the  fre- 
quency of  the  occurrence  of  the  bacilli  in  the  blood  is  supported  by 
clinical  and  anatomical  facts,  we  are  justified  in  considering  these 
acid-fast  rods  as  tubercle  bacilli. 

The  finding  of  these  bacilli  in  the  blood  is  of  no  potential  diag- 
nostic and  prognostic  value,  while  about  their  immunizing  effects  we 
cannot  speak  with  any  degree  of  certainty. 

THE   RENAL   SYSTEM. 

The  Kidneys. — There  appear  to  be  no  changes  in  the  structure  and 
functions  of  the  kidneys  which  can  be  considered  specific  and  char- 
acteristic of  early  phthisis,  excepting  in  cases  with  a  very  acute  onset 
with  high  fever  which  affects  these  organs  in  the  same  manner  as 
hyperthermia  due  to  other  causes,  or  in  cases  in  which  the  kidneys  are 
inoculated  at  the  onset  together  with  many  other  organs,  as  in  acute 
miliary  tuberculosis. 

Some  writers,  notably  the  French,  have  described  polyuria,  phospha- 
turia  and  albuminuria  as  very  frequent  in  early  and  even  in  latent 


1  Amer.  Jour.  Med.  Sci.,  1915,  cl,  377. 

2  Ztschr.  f.  klin.  Med.,  1914,  Ixxx,  88. 


228  SYMPTOMS  REFERABLE  TO  RENAL  SYSTEM 

phthisis.  Barbier^  says  that  albuminuria  is  often  the  only  sign  observed 
for  a  long  time  before  other  s,ymptoms  make  their  appearance;  and 
that  this  albuminuria  is  often  misunderstood  by  phj'sicians.  Albert 
Robin^  describes  pretuberculous  polyuria:  The  quantity  of  urine  in 
the  early  stage  is  increased;  in  the  second  stage  normal;  and  in  the 
third  stage  diminished,  although  some  patients  have  polyuria  through- 
out the  course  of  the  disease.  The  oliguria  of  the  advanced  stage  is 
closely  related  to  the  fever,  sweats,  and  eventual  diarrhea.  Robin 
maintains  that  the  polyuria  of  early  phthisis  is  simple,  showing  no 
abnormal  constituents  or,  at  most,  there  may  be  phosphaturia,  when, 
at  times,  it  may  be  severe  enough  to  cause  irritation  of  the  kidney 
substance,  congestion,  and,  finally,  albuminuria. 

These  changes  have,  however,  not  been  met  with  sufficient  constancy 
to  place  them  in  the  category  of  pathognomonic  or  specific  symptoms 
of  early  tuberculosis.  Among  100  cases  of  early  tuberculosis  that  I  have 
especially  investigated  for  the  purpose  of  testing  this  point,  I  found 
albuminuria  in  only  9  cases,  and  casts  in  only  3. 

Albuminuria  in  Advanced  Cases. — In  the  advanced  stages  albumin- 
uria is  very  frequent.  Montgomery  found  albumin  present  in  about 
one- third  of  cases  of  phthisis.  In  the  majority  of  cases  the  amount 
was  only  a  trace  and  when  found  in  larger  amounts  it  was  always 
associated  with  casts  and  blood  or  pus.  It  appears  that  cases  with 
intestinal  ulcers  have  larger  amounts  of  albumin  than  others.  From 
his  studies  he  arrives  at  the  conclusion  that  a  large  number  of  casts  in 
the  urine  of  consumptives  is  indicative  of  an  unfavorable  prognosis, 
and  the  reverse. 

As  to  the  causes  of  the  albuminuria  we  are  not  clear.  Some  look  upon 
it  as  caused  by  the  irritation  of  the  tuberculous  toxins,  which  are  elim- 
inated with  the  urine,  on  the  renal  parenchyma,  while  others  see  in  it 
the  effects  of  the  chronic  fever,  or  actual  tuberculosis  of  the  kidneys. 
In  an  exhaustive  study  of  the  problem,  N.  Leon-Kin dberg^  arrives  at 
the  conclusion  that  the  so-called  "tuberculotoxins"  cause  no  lesions 
in  the  kidneys.  The  presence  of  isolated  tubercles  in  the  kidneys 
explains  perhaps  some  cases  of  bacteriuria. 

It  must  be  mentioned  that  mixed  infection,  such  as  is  seen  in  pul- 
monary cavities  containing  in  addition  to  tubercle  bacilli  also  pyogenic 
microorganisms,  is  usually  the  cause  of  albuminuria  in  the  advanced 
stages  of  phthisis  where  there  is  no  concomitant  renal  tuberculosis. 

Nephritis  in  the  Course  of  Phthisis. — Symptoms  of  acute  nephritis 
are  very  rarely  met  with  during  the  course  of  phthisis;  but  the  chronic 
degenerative  forms,  parenchymatous  and  interstitial  have,  however, 
been  found  in  variable  proportions.  Bamberger  found  nephritis  to- 
gether with  phthisis  to  the  extent  of  15  per  cent.;  Potain  states  that 
one-fifth  of  all  consumptives  have  nephritis;    and  others  have  found 

'  Brouaidcl  and  Gilliert's  Traite  de  Modccinc,  Paris,  19 U),  xxix,  42.'). 
2  Traitement  do  la  tubercviloso,  p.  498. 
sfitudes  sur  le  rein  des  tuberculeux,  Paris,  1913. 


THE  RENAL  SYSTEM  229 

even  higher  percentages.  Senator  was  inchned  to  the  opinion  that 
tuberculosis  is  an  important  etiological  factor  in  chronic  parenchy- 
matous nephritis.  But  it  appears  that  clinical  symptoms  of  nephritis 
are  usually  altogether  absent,  even  when  albumin  and  casts  are  found 
in  the  urine,  and  cardiac  hypertrophy  is  exceedingly  rare. 

Most  of  these  views  are  based  on  the  presence  of  albumin  in  the 
urine,  and  Montgomery^  has  shown  that  in  pulmonary  tuberculosis 
albumin  and  casts  are  not  often  associated  with  evidences  of  nephritis. 
In  phthisis,  albuminuria  is  not  necessarily  a  manifestation  of  nephritis, 
or  even  of  renal  tuberculous  lesions,  but  in  many  cases,  especially  in 
fibroid  phthisis  and  emphysema,  it  is  due  to  cardiac  dilatation,  to 
intestinal  and  hepatic  disturbances,  etc.,  which  are  so  frequent  in 
advanced  phthisis.  Albuminuria  may  also  be  the  sole  indication  of  a 
tuberculous  lesion  in  a  kidney  which  manifests  itself  by  no  other 
symptom  during  life.  Thus,  in  a  painstaking  study  of  106  pairs  of 
kidneys  taken  from  consumptives,  made  by  J.  Walsh,^  53.9  per  cent, 
were  found  to  contain  tubercles.  He  also  found  that  among  these  106 
pairs  of  kidneys  only  10  showed  chronic  interstitial  nephritis,  while  in 
44  kidneys  from  patients  suffering  from  other  chronic  diseases,  there 
were  23  with  this  form  of  nephritis,  which  clearly  indicates  that 
tuberculosis  of  the  lungs  is  antagonistic  to  the  ordinary  chronic 
general  interstitial  nephritis,  just  as  it  appears  antagonistic  to  general 
sclerosis  of  other  organs. 

The  Amyloid  Kidney.— In  the  far-advanced  stages  of  phthisis 
with  large  suppurating  cavities  in  the  lungs,  we  often  encounter 
amyloid  degeneration  of  the  kidneys,  as  in  cachexia  due  to  other 
causes.  It  is  usually  found  associated  with  amyloid  changes  in  other 
organs,  notably  the  liver,  spleen,  and  intestines.  But  even  this  is  not 
as  frequent  as  would  be  expected.  White  found  9.2  per  cent.;  Walsh 
6.6  per  cent.,  and  he  never  found  it  exclusively  in  the  kidneys;  Blum 
in  only  6  per  cent.,  but  he  points  out  that  79.2  per  cent,  of  all  amyloids 
were  caused  by  tuberculosis,  of  which  54.4  per  cent,  is  pulmonary 
phthisis. 

Its  symptomatology  is  that  of  amyloid  disease  of  the  liver  and  intes- 
tines, and  because  it  is  always  associated  with  other  changes  in  the 
kidneys,  such  as  chronic  parenchymatous  nephritis,  the  resulting 
symptoms  are  always  complex.  Albumin  is  usually  present  in  the  urine. 
I  find  it  safe  to  conclude,  when  the  liver  is  enlarged  and  there  is  pro- 
fuse diarrhea,  that  there  is  no  doubt  that  the  kidneys  are  amyloid. 
But  when  there  is  no  diarrhea,  there  is  polyuria  of  low  specific  gravity, 
casts  and  but  little  albumin. 

Terminal  Edema. — Edema  is  present  in  a  large  proportion  of  cases 
of  advanced  phthisis;  the  ankles  and  knees  especially  are  thus  affected 
during  the  terminal  stages,  but  it  does  not  always  depend  on  the  con- 
dition of  the  kidneys.    Montgomery  found  no  relation  between  edema 

^  Fourth  Annual  Report  Henry  Phipps  Institute,  1908,  p.  120. 
2  Trans.  Sixth  Intern.  Congr.  Tuberc,  1908,  i,  347. 


230  SYMPTOMS  REFERABLE  TO  RENAL  SYSTEM 

and  the  occurrence  of  albumin  and  casts  in  the  urine,  and  suggests 
that  the  edema  found  in  tuberculosis  does  not  depend  primarily  on 
nephritis.  General  anasarca  is  often  seen  in  far-advanced  cases  toward 
the  end,  and  this  may  be  a  manifestation  of  the  state  of  the  kidneys, 
but  when  we  bear  in  mind  that  in  these  cases  we  also  have  cardiac 
dilatation,  it  is  clear  that  the  pathogenesis  is  often  complex. 

The  edema  may  be  considered  an  ill  omen,  and  I  have  not  seen  a 
consumptive  with  edematous  ankles  and  knees  survive,  or  even 
improve.  It  may  be  unilateral,  sometimes  one-half  of  the  body  is 
swollen  and  pitting,  corresponding  to  the  side  on  which  the  patient 
lies.  At  times  we  see  it  only  in  one  upper  extremity,  due  to  pressure 
on  the  veins  coming  from  the  arm  by  tuberculous  glands,  or  when  they 
are  implicated  in  the  adhesive  pleurisy  of  that  side  and  more  com- 
monly by  thrombosis  of  the  innominate,  subclavian  or  other  veins. 
Phlebitis  or  thrombosis  of  the  femoral,  popliteal  and  crural  veins  is 
even  more  frequent  (see  Chapter  XXVI). 

Uremia. — Symptoms  of  uremia  are  not  often  met  with  in  phthisis, 
but  not  so  rarely  as  some  authors  would  lead  us  to  believe.  In  the 
advanced  stages  we  meet  at  times  with  typical  uremia  which  is  often 
mistaken  for  meningeal  infection.  I  have  seen  three  cases  of  convul- 
sions due  to  this  cause.  In  severe  dyspnea  without  fever,  arising  sud- 
denly, uremia  is  to  be  thought  of  in  cases  with  albumin  and  casts  in 
the  urine.  Some  diarrhea  observed  in  these  cases  is  distinctly  of  uremic 
origin,  and  at  times  we  meet  with  pulmonary  edema.  They  are  usually 
very  difficult  of  recognition  and  differentiation. 


CHAPTER  XIII. 
NERVOUS  SYMPTOMS  OF  PHTHISIS. 

As  an  exquisitely  chronic  disease,  phthisis  is  accompanied  by  many 
morbid  manifestations  of  the  nervous  system;  in  fact,  nearly  every 
symptom  of  the  disease  is  often  influenced  by  the  effects  of  the 
tuberculous  toxins  on  the  nervous  system.  The  neurotic  phenomena 
may  make  their  appearance  immediately  at  the  outset,  in  some 
they  precede  the  actual  onset  of  phthisis,  while  most  of  confirmed 
consumptives  have  a  psychology  peculiarly  their  own  and  show  symp- 
toms of  nervous  aberration  which  cannot  escape  the  vigilance  of  the 
observant  physician. 

Neurasthenia  and  Psychasthenia. — The  onset  of  phthisis  is  often 
accompanied  by  symptoms  simulating  that  syndrome  which  is  known 
under  the  vague  term  of  neurasthenia;  indeed,  many  patients  have 
been  treated  for  neurasthenia  for  months  before  the  true  nature  of 
their  affection  was  recognized.  These  symptoms  have  been  described 
by  many  authors  and  deserve  careful  consideration. 

A  large  proportion  of  incipient  and  confirmed  consumptives  complain 
of  vertigo,  headache,  pains  along  the  spine,  irritability  of  temper, 
insomnia,  not  necessarily  due  to  nightsweats,  and  fleeting  pains  of  the 
chest  which  at  times  cannot  be  attributed  to  circumscribed  pleurisy; 
frequent  attacks  of  tachycardia,  irrespective  of  the  temperature  and 
cardiac  palpitation  are  not  rare.  There  is  also  the  characteristic 
languor  and  persistent  weariness,  which  is  not  relieved  by  sleep ;  on 
the  contrary,  many  state  that  they  feel  more  weary  and  tired  in  the 
morning  on  getting  out  of  bed,  and  that  this  tired  feeling  wears  off 
in  the  afternoon  or  evening,  all  of  which  is  suggestive  of  neurasthenia 
and  psychasthenia.  Considering  these  symptoms  there  is  little 
wonder  that  many  patients  are  treated  for  "nervousness"  until  an 
attack  of  dry  or  moist  pleurisy,  or  of  hemoptysis  or  a  careful  examina- 
tion of  the  chest,  reveals  the  true  state  of  affairs.  Papillon^  goes  so 
far  as  to  say  that  he  suspects  every  victim  of  neurasthenia  to  be  a 
subject  of  latent  tuberculosis,  and  G.  D.  Head^  considers  a  considerable 
proportion  of  neurasthenics  as  harboring  a  tuberculous  infection  which 
is  so  concealed  that  it  escapes  detection  by  the  usual  clinical  methods. 
Considering  that  neurasthenia  is  quite  often  the  result  of  toxic  causes, 
it  is  clear  that  tuberculous  toxemia  may  be  a  cause  of  these  symptoms 
in  many  cases.     If  the  chests  of  all  patients  treated  for  neurasthenia 

1  Arch,  de  Scien.  Medicales,  1900,  v,  19. 

2  Jour.  Amer.  Med.  Assn.,  1914,  Ixiii,  996. 


232  NERVOUS  SYMPTOMS  OF  PHTHISIS 

were  carefully  examined,  a  large  proportion  of  phthisis  which  is  now 
only  recognized  in  the  advanced  stages  would  be  identified  at  earlier 
stages. 

Reflex  Nervous  Phenomena. — Aberrations  of  the  sympathetic 
nervous  system  are  not  rare  in  phthisis.  Among  these  may  he  men- 
tioned the  unilateral  flushes  of  the  face  and  occasionally  of  one  ear, 
combined  with  a  feeling  of  warmth,  sweating,  etc.  In  some  cases 
it  has  been  observed  that  the  cutaneous  temperature  is  higher  on  one 
side  of  the  chest.  These  unilateral  symptoms  are  usually  found  on  the 
side  corresponding  to  the  affected  hemothorax  and,  in  bilateral  lesions, 
to  the  side  in  which  the  recent  or  more  active  lesion  is  located.  In 
some  patients  with  extensive  excavations  in  the  lung,  the  nostril 
corresponding  to  the  affected  side  is  widely  dilated.  Dermographism 
is  very  frequent. 

An  important  symptom  of  phthisis  is  dilatation  of  the  pupils,  to 
which  Rogue,^  Destree,^  and  also  T.  F.  Harrington^  drew  attention. 
Harrington  described  the  widely  dilated  pupils  as  "not  a  paralyzed 
pupil,  but  rather  one  which  seems  to  be  in  a  more  or  less  constant 
state  of  dilatation,  due  to  some  irritation  along  the  track  of  the  nerve 
fibers  in  the  celiospinal  region,"  and  says  that  they  may  be  found 
in  cases  before  the  evidences  of  active  disease  can  be  discovered.  But 
dilatation  of  but  one  pupil  is  more  frequent,  some  authors  saying 
that  it  occurs  in  more  than  50  per  cent,  of  cases;  that  it  is  an  early 
symptom  and  may  be  found  before  other  symptoms  and  signs  make 
their  appearance.  It  is  said  to  be  caused  by  irritation  of  the  cervical 
sympathetic  by  the  inflammatory  process  in  the  apex  and  pleura. 
With  the  improvement  in  the  disease  the  difference  in  the  pupils  may 
disappear,  but  I  have  seen  it  persist  after  the  patient  recovered.  At 
times,  one  pupil  is  unduly  contracted. 

Muralt^  pointed  out  that  these  unilateral  nervous  phenomena  may 
be  observed  within  certain  limits  experimentally  after  the  induction 
of  therapeutic  pneumothorax.  He  found  that  with  the  increase  in  the 
intrapleural  pressure,  the  pupil  dilates  and  the  cheek  flushes  on  the 
affected  side,  and  in  some  cases  there  are  tj^ical  attacks  of  migraine, 
while  with  the  decrease  in  the  pressure  the  phenomena  disappear. 

Pains. — ^While  a  large  proportion  of  tuberculous  patients  pass 
through  the  disease  painlessly,  there  are  many  who  suffer  from  pains 
and  aches  of  various  degrees  of  severity.  The  pains  may  be  in  any 
part  of  the  body,  but  the  most  characteristic  are  those  of  the  chest 
and  upper  extremity.  Kuthy  found  that  among  650  patients,  60  per 
cent,  had  pains  in  the  chest  and  of  these  it  was  localized  in  85  per  cent, 
in  the  affected,  or  more  affected  side. 

Many  of  my  patients  have  received  the  first  intimation  of  trouble 

'  Gaz.  med.  de  Paris,  1869. 
^  .lour,  de  med.  et  de  pharmacol.,  1894,  241. 
3  Boston  Med.  and  Surg.  Jour.,  1899,  cli,  575. 
^Mediz.  Klinik,  1913,  ix,  1814  and  1901. 


PAINS  233 

with  their  lungs  through  pains  which  were  usually  felt  in  the  infra- 
clavicular space  above  the  second  rib  and  more  often  in  the  supra- 
spinous fossa,  between  the  shoulder-blades  or  under  them.  It  is 
usually  of  a  dull  character,  uninfluenced  by  motion,  breathing  or 
coughing,  worse  during  the  night.  The  skin  over  the  affected  area 
is  only  rarely  tender,  but  deep  pressure  almost  invariably  aggravates 
it;  tapping  this  region  may  bring  on  a  coughing  spell.  Hyperesthesia 
of  the  spine  between  the  shoulder-blades  is  quite  common. 

In  more  advanced  phthisis  pains  in  the  shoulder  may  be  actually 
agonizing,  worse  during  the  night  depriving  the  patient  of  his  sleep 
and  resisting  all  therapeutic  efforts  at  relief.  When  occurring  in  the 
incipient  stage  they  are  not  so  acutely  felt,  but  may  extend  all  along 
the  arm  and  forearm  down  to  the  finger  tips.  Minor  exposures  to  the 
vicissitudes  of  the  weather  may  bring  about  pains,  and  the  patient  then 
believes  that  he  is  affected  with  rheumatism.  In  fact,  many  cases 
of  "rheumatism"  of  the  shoulder  turn  out  to  be  phthisis.  Diaphrag- 
matic pains  are  frequent.  They  are  described  by  the  patients  as 
stabbing  in  character,  or  as  if  there  was  a  wound  in  that  region,  and 
are  usually  due  to  pleural  adhesions  and  may  be  aggravated  by  deep 
breathing,  coughing  and  sneezing. 

Hyperesthesia  is  very  rare  in  phthisis.  The  pains  are  usually 
elicited  by  pressure  on  the  regional  muscles  over  the  affected  parts 
of  the  lung.  When  the  apex  is  affected,  the  sternocleidomastoidei 
and  the  trapezii  may  be  painful;  when  the  lesion  is  more  extensive 
the  scaleni,  pectorales  and  intercostals,  and  when  there  is  a  lesion  at 
the  base,  the  lumbar  muscles  may  be  painful  on  pressure.  In  pleurisy 
the  same  phenomena  may  be  observed.  These  pains  are  not  due  to 
cough  because  they  are  unilateral.  They  are  accompanied  by  spas- 
modic contractions  of  the  regional  muscles,  caused  by  reflex  irritation 
of  the  supplying  nerves. 

These  pains  have  been  studied  very  carefully  by  Henry  Head,^ 
James  Mackenzie,-  and  more  recently  in  this  country  by  Lovell  Langs- 
troth.^  Head  found  that  these  pains  were  either  local  or  referred,  and 
when  due  to  pleurisy  they  coincided  precisely  with  the  situation  of 
the  pleural  area  involved  and  were  accompanied  by  deep  tenderness, 
but  not  by  superficial  hyperalgesia.  In  cases  of  phthisis  marked  by 
successive  acute  or  subacute  attacks  involving  previously  healthy 
parts  of  the  lung,  referred  pains  were  mostly  found.  He  attributed 
them  to  the  fact  that  the  end-organs  of  the  sensory  nerves  in  the  por- 
tion of  the  lung  invaded  remained  intact  and  capable  of  conveying  im- 
pressions when  irritated.  These  nerve  endings  were  destroyed  after  the 
disease  advanced,  causing  necrosis,  and  were  no  more  capable  of  causing 
referred  pain.  Superficial  tenderness  is  particularly  liable  to  spread 
along  the  paths  of  the  nerves  and  Head  believed  it  due  to  the  cachexia 

1  Brain,  1896,  xix,  153. 

2  Symptoms  and  their  Interpretation,  London,  1909. 

3  Arch.  Intern.  Med.,  1915,  xvi,  149. 


234  NERVOUS  SYMPTOMS  OF  PHTHISIS 

and  pyrexia  characteristic  of  each  acute  exacerbation  of  the  disease. 
Within  certain  limits,  he  was  able  to  determine  the  lung  area  involved 
by  the  cutaneous  hyperalgesia.  A  review  of  the  various  forms  of  pains 
in  phthisis  is  given  by  F.  Jessen^  and  J.  L.  Pomeroy^  in  special 
monographs.  It  appears,  howeyer,  that  Langstroth's  conclusion  to 
the  effect  that  this  hyperalgesia  is  practically  of  no  importance  in 
diagnosis,  or  in  localizing  pulmonary  lesions,  is  correct. 

It  appears  that  the  tenderness  found  in  active  phthisis  is  the  result 
of  an  attempt  on  the  part  of  the  muscles  to  protect  the  diseased  viscera 
beneath  them.  It  is  replaced  by  muscular  atrophy  in  the  later  stages 
of  phthisis. 

The  origin  of  the  various  pains  in  phthisis  is  not  always  clear. 
It  has  been  shown  by  J.  Mackenzie  that  the  lung  is  insensitive  to 
stimulation  when  healthy  or  diseased,  as  is  evident  from  the  fact  that 
when  an  exploring  needle  penetrates  the  lung  the  patient  feels  no 
pain.  In  fact,  no  form  of  stimulation  of  lung  tissue  seems  to  be  capable 
of  producing  sensation,  directly  or  reflexly.  It  is  for  this  reason  that 
necrosis  of  lung  tissue,  as  it  occurs  in  gangrene,  abscess  or  tuberculous 
cavity  formation  is  usually  painless. 

The  suggestion  that  the  pains  in  phthisis,  as  well  as  in  pleurisy 
and  pneumonia  are  due  to  pleural  involvement  does  not  hold  either, 
because  the  pleura  is  insensitive.  Mackenzie  states  that  he  repeatedly 
explored  the  pleural  cavity  for  any  evidences  of  sensation  and  could 
employ  no  form  of  stimulation  capable  of  producing  pain.  When 
inducing  therapeutic  pneumothorax  I  have  repeatedly  observed  that 
entering  the  parietal  pleura  with  the  needle  produced  no  pain,  nor 
does  scratching  the  visceral  pleura  with  the  point  of  the  needle  produce 
any  sensation.  Mackenzie  is  therefore  inclined  to  attribute  pains 
of  the  kind  mentioned  above  to  contraction  of  the  overlying  muscles. 
This  is  the  reason  why  no  hyperesthesia  of  the  skin  is  met  with  in 
phthisis,  but  pressure  pain  is  frequent.  It  is  due  to  a  visceromotor 
reflex  and  occurs  along  the  distribution  of  the  sensory  nerves  which 
are  stimulated  by  the  lesion.  The  above-mentioned  pain  in  the  shoulder 
can  be  explained  by  irritation  in  diaphragmatic  pleurisy  of  the  phrenic 
nerve  and  conducts  the  stimulus  to  the  skin  of  the  shoulder.  Both 
the  phrenic  and  fourth  cervical  nerves  leave  the  spinal  cord  at  the 
same  place  and  the  former  nerve  conducts  afferent  fibers  as  well  as 
efferent  (motor),  and  it  is  in  all  probability  by  the  former  that  the 
stimulus  is  conveyed  to  the  centre  of  the  fourth  cervical  nerve  in  the 
cord.  Pottenger  also  attributes  these  shoulder  pains  to  an  inflammation 
of  the  nerve  resulting  from  the  reflex  segmental  stimulation — a  true 
neuritis.  On  the  other  hand,  a  recent  investigation  by  Capps'^  seems 
to  indicate  that  irritation  of  the  central  part  of  the  diaphragmatic 
pleura  gives  referred  pain  in  the  neck;  and  irritation  of  other  parts 

1  Lungenschwindsucht  und  Nervensystem,  Jena,  1905. 

2  Interstate  Med.  Jour.,  1912,  xix. 
■'Arch.  Intern.  Med.,  1911,  viii. 


PSYCHIC   TRAITS  235 

also  give  rise  to  true  referred  pains,  set  up  by  impulses  carried  to  the 
third  and  fourth  cervical  segments  by  the  phrenic  nerve,  and  thence 
to  the  areas  of  these  segments. 

During  the  last  few  days  of  life  the  reflexes  are  usually  abolished 
in  the  phthisical  and  they  are  relieved  from  all  pains ;  in  fact,  at  times 
we  find  them  very  hopeful  because  they  feel  no  more  pains. 

Psychic  Traits. — Psychoses  met  with  among  tuberculous  patients 
may  be  considered  in  the  main  as  coincidences,  because  so  many  people 
suffer  from  phthisis,  and  inasmuch  as  this  disease  is  no  bar  against 
mental  alienation,  it  is  but  natural  that  some  should  become  insane 
from  any  of  the  causes  of  this  aberration.  It  is  a  fact  that  an  enormous 
proportion  of  insane  die  from  phthisis — Clouston^  states  that  two- 
thirds  of  deaths  among  idiots  result  from  tuberculosis — but  this  may 
be  due  to  their  irrational  mode  of  life,  as  well  as  to  their  confinement 
in  institutions.  Delirium  is  also  very  often  seen  in  the  terminal  stages 
of  phthisis  and,  when  not  due  to  meningeal  complication,  it  does  not 
differ  from  the  delirium  seen  in  inanition,  exhaustion  or  febrile  in- 
toxication due  to  other  causes.  But  in  addition  to  these  occasional 
psychic  disturbances,  wdiich  might  be  expected,  there  have  been  noted 
other  psychic  disturbances  in  phthisical  patients  and  many  authors 
have  spoken  of  a  characteristic  psychology  of  the  consumptive. 

Many  tuberculous  patients  show  a  remarkable  change  in  their 
mental  traits  and  character,  a  disturbance  in  their  emotional  life  and 
a  striking  divergence  from  their  previous  customs,  habits,  affections, 
and  tastes.  In  some,  this  change  precedes  the  evident  onset  of  the 
disease,  in  many  it  appears  synchronously  with  the  symptoms  of  active 
disease;  it  may  ameliorate  with  each  improvement  and  aggravate 
with  each  acute  exacerbation. 

This  change  in  character  manifests  itself  in  various  other  ways: 
Liberal  persons  may  become  stingy  and  misanthropic,  brave  ones 
become  cowardly,  etc.  EngeP  points  out  that  the  original,  innate 
temperament  or  character  of  the  individual  becomes  strikingly  pro- 
nounced in  the  chronic  consumptive:  The  pessimist  suffers  from 
marked  despondency;  the  optimist  becomes  unreasonably  hopeful  of 
the  ultimate  outcome,  etc.  These  phenomena  may  be  explained  by 
the  discordance  between  the  subjective  feelings  of  the  patient  who  is 
not  as  disabled  as  the  objective  findings  of  the  physican  would  lead 
to  expect.  The  mental  make  up  of  the  patient  depends  greatly  on 
his  physical  condition  which,  in  tuberculosis,  is  subject  to  great 
oscillations;  aggravations  and  improvements  coming  and  going  quite 
unexpectedly.  The  mental  traits  per  se  do  not  change,  but  such  traits 
as  were  characteristic  during  youth  but,  as  a  result  of  education, 
training  and  the  vicissitudes  of  life,  have  been  suppressed,  reappear 
boldly,  unhindered  by  conventionalities. 

A  psychic  trait  of  the  consumptive  which  has  been  noted  by  most 

1  AUbutt's  System  of  Medicine,  viii,  307. 

2  Miinch.  med.  Wchnschr.,  1902,  xlix,  1.383. 


236  NERVOUS  SYMPTOMS  OF  PHTHISIS 

writers  is  selfishness.  He  becomes  egotistical  and  egocentric.  He  is 
interested  in  the  welfare  of  but  one  person — himself — to  the  exclusion 
of  all  who  have  depended  on  him  before.  He  will  eat  costly  food 
while  his  children  starve;  he  will  make  unreasonable  demands  on  his 
relatives  and  friends  and  show  no  gratitude.  In  sanatoriums  this  has 
been  the  most  important  problem  with  which  the  officers  have  to  cope, 
and  the  failure  of  many  superintendents  is  due  to  their  lack  of  appre- 
ciation of  this  trait  of  the  consumptive.  As  Saxe^  states,  the  ascendence 
of  selfishness  plays  the  most  important  role  in  the  molding  of  the 
mental  traits  of  the  tuberculous.  In  some  patients  these  factors  are 
so  pronounced  that  they  completely  reveal  the  concealed  elements  of 
their   character. 

Euphoria  and  Euthanasia. — Optimism,  despite  many  evidences  of 
progressive  disease  which  saps  the  body,  is  frequent;  only  a  copious 
hemorrhage,  or,  more  rarely,  a  spontaneous  pneumothorax,  will  terrify 
the  average  tuberculous  patient.  Otherwise,  all  the  symptoms  amount 
to  little  or  nothing:  An  increase  in  the  cough  is  due  to  a  "cold;" 
anorexia  is  caused  by  bad  food,  etc. 

Barring  the  functional  neuroses,  there  are  no  diseases  in  which 
suggestion — auto-  and  heterosuggestion — is  so  effective  in  modifying 
the  course  of  the  malady  or  in  relieving  symptoms.  An  injection  of 
water  will  induce  sleep,  relieve  pain,  cough,  etc.,  and  even  produce 
an  increase  in  temperature  exactly  like  that  of  the  tuberculin  reaction. 
In  many  European  sanatoriums  there  is  a  routine  measure  before 
applying  tuberculin  for  diagnostic  purposes,  to  inject  water  with  a 
view  of  ascertaining  whether  the  fever  is  due  to  psychic  effects  or  to 
the  tuberculin.  It  has  been  found  that  20  per  cent,  of  patients  react 
to  the  injedio  vacna.  Some  physicians  have  been  able  to  suggest  the 
hour  of  the  day  when  the  reaction  will  appear,  as  well  as  any  or  all 
the  symptoms  which  make  up  the  typical  tuberculin  reaction.  The 
effects  of  this  high  susceptibility  to  suggestion  are  seen  in  phthisio- 
therapy;  quack  doctors  and  remedies  are  thriving  on  consumptives 
more  than  on  any  other  class  of  patients,  excepting  perhaps  the  vene- 
real in  whom  the  element  of  secrecy  is  of  importance. 

The  proverbial  euphoria  and  euthanasia  of  the  consumptive,  which 
have  been  described  in  such  great  detail  by  many  medical  authors  and 
which  have  not  escaped  the  attention  of  writers  of  fiction  for  strong 
dramatic  effects,  are  other  manifesfations  of  the  proclivities  to  auto- 
suggestion. Experience  has  taught  that  when  a  patient  with  excessive 
excavations  in  the  lungs,  running  high  fever,  and  presenting  other 
symptoms  and  signs  of  this  condition,  begins  to  believe  that  he 
has  improved,  that  he  "feels  fine,"  has  no  pains,  does  not  cough 
distressingly,  we  may  look  for  a  speedy  relief  of  the  unfortunate  by 
that  greatest  of  benefactors  for  these  desperate  sufi'erers,  death.  It 
is  often  astonishing  to  behold  the  sinking  man  make  plans  for  the 

1  New  York  Med.  Jour.,  1903,  Ixxviii,  211  and  263. 


INSOMNIA  237 

future,  engage  in  new  enterprises,  plan  long  voyages — not  for  a  cure, 
which  he  believes  he  has  almost  attained,  but  for  pleasure — or,  as  1 
have  seen,  arranging  for  his  marriage  a  few  days  before  his  death. 

Very  often  this  optimism  and  euphoria  are  excellent  aids  in  our 
attempts  at  curing  these  patients.  It  is  a  well-known  fact  that  there 
is  hardly  any  hope  for  a  despondent  consumptive.  On  the  other 
hand,  this  euphoria  is  occasionally  harmful  because  it  misleads  the 
patient  and  he  neglects  the  instructions  of  his  physician. 

It  appears  that  as  a  result  of  the  prolonged  state  of  intoxication 
produced  by  the  absorption  of  the  poisons  resulting  from  the  metab- 
olism of  the  tubercle  bacilli  as  well  as  of  the  products  of  decom- 
position of  the  affected  lung  tissue,  the  consumptive  is  in  about  the 
same  mental  state  as  those  who  are  under  the  influence  of  mild  alcoholic 
intoxication.  The  external  appearance  of  the  consumptive  betrays 
his  state  of  intoxication.  His  bright  eyes  with  dilated  pupils,  which 
are  at  times  contracted  unilaterally,  the  flushing  cheeks,  the  keen 
intellect  which  is  so  often  met  with  among  those  who  before  the 
onset  of  the  disease  were  rather  dull  in  this  respect,  coupled  with  a 
flickering  intelligence  which  brightens  up  suddenly  for  a  few  hours 
but  is  soon  followed  by  mental  depression  or  fatigue,  bear  close 
resemblance  to  the  average  person  who  is  under  the  influence  of 
moderate  doses  of  alcohol  or  a  narcotic  drug. 

In  tuberculous  patients,  particularly  young  talented  individuals,  it 
is  noted  that  for  a  few  weeks  or  months  now  and  then  they  display 
enormous  intellectual  capacity  of  the  creative  kind.  Especially  is 
this  to  be  noted  in  those  who  are  of  the  artistic  temperament,  or 
who  have  a  talent  for  imaginative  writing.  They  are  in  a  constant 
state  of  nervous  irritability,  but  despite  the  fact  that  it  hurts  their 
physical  condition,  they  keep  on  working  and  produce  their  best 
work.  This  spes  phthisica  has  been  described  by  many  authors, 
notably  by  J.  B.  Huber^  and  A.  C.  Jacobson^  in  this  country.  They 
maintain  that  "the  quality  of  genius  may,  in  some  cases  at  least, 
be  affected  by  tuberculosis,"  and  that  the  intellectual  powers  of  the 
genius  are  quickened  by  reason  of  the  general  psychic  exitation  result- 
ing from  the  action  of  the  tuberculous  by-products.  "They  astonish 
everybody,"  says  Letulle,^  "with  their  mental  and  intellectual  activity; 
their  memory,  their  quick  judgment,  their  delicate  reasoning  powers 
are  of  incomparable  amplitude." 

The  long  list  of  great  writers  and  artists  given  by  Huber  and  Jacob- 
son,  to  which  many  more  may  be  added,  shows  that  tuberculosis  is 
rather  frequent  among  talented  individuals,  and  suggests  that  it  may 
be  enhancing  their  productivity  instead  of  reducing  it  as  would  be 
expected  a  priori. 

Insomnia. — Insomnia  in  the  early  stages  of  phthisis  may  be  due 
to  restlessness  owing  to  worry  because  of  the  diagnosis  of  a  dangerous 

1  Consumption  and  Civilization,  Philadelphia,  1906. 

2  Interstate  Med.  Jour.,  1914,  xxi,  341.  3  ^rch.  gen.  de  med.,  1900,  ii,  258. 


238  NERVOUS  SYMPTOMS  OF  PHTHISIS 

disease,  and  is  often  removed  by  emphatically  reassuring  the  patient. 
Indeed,  the  characteristic  attitude  of  optimism  soon  prevails  and 
the  patient  is  no  more  disturbed  by  insomnia. 

In  others  insomnia  is  due  to  excessive  cough,  or  nightsweats,  or 
both.  In  some  cases  the  administration  of  hypnotic  remedies  is  of 
no  avail  so  long  as  they  are  given  in  safe  doses.  Especially  prone  to 
insomnia  are  patients  who  suffer  from  paroxysmal  attacks  of  cough, 
each  fit  waking  them  and  keeping  them  awake  for  one-half  to  two 
hours.  In  these  cases  the  administration  of  codein,  heroin,  etc.,  is 
imperative.  Profuse  nightsweats  often  act  the  same  way:  After 
waking  bathed  in  perspiration,  the  patient  finds  it  difficult  to  fall 
asleep  again. 

During  the  advanced  stages  many  patients  find  it  very  hard  to  sleep 
because  of  the  copious  secretions  in  the  pulmonary  cavities  which, 
after  a  short  nap,  overflow  the  bronchi  and  compel  them  to  rise  and 
expel  it  from  the  chest.  Some  with  unilateral  lesions  may  be  able  to 
sleep  the  greater  part  of  the  night  in  certain  positions,  and  they  adapt 
themselves  to  the  conditions.  But  in  others  with  cavities  in  both 
lungs,  or  with  sinuses  leading  from  the  cavities  in  different  directions, 
the  prone  posture  immediately  induces  cough.  Some  have  to  sleep 
with  the  face  downw^ard  if  they  want  to  avoid  cough,  others  in  the 
semireclining  posture,  etc.  We  also  meet  with  cases  in  which  dyspnea 
is  the  cause  of  insomnia.  While  during  the  early  stages  of  phthisis 
fever  may  be  the  cause  of  insomnia,  it  is  only  rarely  the  case  during 
the  advanced  stages.  The  average  consumptive  has  adapted  his 
organism  to  the  fever  and  does  not  mind  it  any  more.  Tuberculous 
patients  with  high  fever  are  often  seen  sleeping  quite  soundly  as 
long  as  the  cough,  nightsweats,  and  dyspnea  do  not  disturb  them. 

In  the  terminal  stage  we  often  observe  abnormal  somnolence  in 
phthisical  patients.  For  days,  at  times  for  weeks,  the  patient  lies 
in  a  semicomatous  condition,  careless  about  his  person,  and  only  now 
and  then  wakes  to  ask  for  some  nourishment.  If  not  due  to  excessive 
sedative  medication,  it  may  be  an  indication  of  meningeal  complica- 
tion. But  I  have  had  cases  in  which  this  abnormal  somnolence  has 
existed  for  several  days  or  weeks  before  death,  but  the  autopsy  showed 
no  meniligeal  tuberculosis.  Some  of  these  patients  have  periods  when 
they  are  mildly  delirious. 

Influence  of  Tuberculosis  on  the  Sexual  Sphere. — The  tuberculous 
toxemia  has  a  profound  influence  on  the  sexual  organs  and  their 
functions.  In  women,  menstrual  disturbances  are  not  uncommon 
during  the  course  of  the  disease,  and  quite  often  these  disturbances 
are  noted  before  the  onset  of  evident  symptoms  of  the  disease.  In 
young  girls  the  appearance  of  menstruation  ma>-  stay  the  progress  of 
the  disease,  as  I  have  seen  in  several  cases.  Probably  for  this  reason 
ancient  clipiciaiis  thought  that  amenorrhea  was  a  cause  of  ])hthisis. 
Now  we  know  it  to  be  an  effect  of  the  disease.  Amenorrhea  is  very 
frequent  during  the  course  of  phthisis,  and  other  menstrual  disturb- 


INFLUENCE  OF   TUBERCULOSIS  ON   THE  SEXUAL  SPHERE     239 

ances,  dysmenorrhea,  menorrhagia,  metrorrhagia,  etc.,  may  be  ob- 
served in  many  cases.  But  I  know  of  a  large  number  of  tuberculous 
women  in  whom  the  menstrual  function  remained  practically  normal 
throughout  the   course   of  the  disease. 

During  the  menstrual  days,  and  at  times  a  few  days  before  the 
appearance  of  the  flow,  there  is  often  observed  an  aggravation  in  the 
pulmonary  condition.  The  fever  may  rise,  the  cough  increases  in 
intensity,  rales  increase  in  number  and  extent,  or  reappear  in  places 
where  they  were  noted  before  but  had  disappeared  and  new  areas  of 
lung  tissue  are  often  invaded  during  this  period.  Hemoptysis  is 
quite  frequent  during  this  period  and  in  rare  cases  it  may  even  replace 
menstruation.  Premenstrual  fever  is  occasionally  noted,  as  was  already 
stated. 

Conception  is  possible  at  any  stage  of  the  disease,  and  the  pregnancy 
may,  and  often  does,  pass  through  almost  normally,  the  child  being  of 
average  weight  but  of  low  vitality.  Reibmeyr  believes  that  tuber- 
culous women  are  more  prolific  than  healthy  women — nature  attempts 
to  compensate  in  quantity  for  inferior  quality.  Abortion  and  mis- 
carriage are  more  apt  to  occur  among  them  than  in  healthy  women. 
It  appears  that  during  pregnancy  the  tuberculous  process  is,  as  a  rule, 
in  abeyance  and  the  patient  may  even  improve.  Writers  of  former 
generations,  like  Cullen,  recommended  marriage  to  tuberculous  girls 
for  this  reason.  Dr.  E.  Warren^  in  a  prize  essay  published  in  1857 
said:  "Pregnancy,  coition,  etc.,  are  particularly  desired  by  women 
affected  with  phthisis,  which  constitutes  a  -pointing  of  nature  toward 
a  remedy  for  the  evils  by  which  the  system  has  been  invaded."  He 
quotes  the  opinions  of  authorities  like  Hippocrates,  Sydenham, 
Montgomery,  Parr,  Rokitansky,  Clark  and  many  others,  who  held 
similar  views  on  the  salutary  effects  of  marriage  and  pregnancy  on 
tuberculosis.  Some  modern  writers  hold  similar  views.  In  a  paper 
published  in  1897  Charles  W.  Townsend,^  speaking  of  cases  observed 
in  the  Boston  Lying-in  Hospital,  says  that  "during  pregnancy  the 
patient  often  seems  better  and  the  disease  appears  in  abeyance," 
and  that  "nature  seems  to  put  forth  a  supreme  effort  to  suppress 
the  disease  during  pregnancy  and  to  make  the  labor  easy  and  short, 
but  after  the  child  is  born  the  disease  advances  at  a  rapid  rate." 

There  is  no  question  that  during  pregnancy  the  more  annoying 
symptoms  are  in  abeyance  in  many  cases.  In  fact,  it  is  rare  to  see  a 
woman  becoming  sick  with  progressive  disease  during  the  period  of 
pregnancy.  But  after  the  child  is  born  the  disease  flares  up  and 
often  begins  to  progress  with  frightful  rapidity.  A  considerable  pro- 
portion of  tuberculous  women  date  back  the  beginning  of  the  disease 
to  childbirth.  Labor  seems  to  stimulate  the  process  in  the  lungs  and 
favors  the  development  of  progressive  disease.  Women  in  the  incipient 
stage  of  phthisis,  and  those  in  whom  the  disease  was  arrested  or  even 

'  Amer.  .Jour.  Med.  Sei.,  18.57,  xxxiv,  87. 

2  Boston  Med.  and  Surg.  Jour.,  1897,  Ixxxviii,  391. 


240  NERVOUS  SYMPTOMS  OF  PHTHISIS 

cured,  are  apt  to  suffer  an  extension  of  the  process,  or  a  relapse  or 
recurrence  of  active  phthisis  after  pregnancy  and  childbirth. 

Sexual  Irritabiliy. — The  popular  views  entertained  by  the  laity 
and  the  profession  to  the  effect  that  consumptives  have  excessive 
sexual  potency  and  demands  are  apparently  well  founded.  Even 
during  the  incipient  stage  of  the  disease  there  is  often  noted  an  in- 
creased sexual  irritability,  and  this  is  apparently  the  reason  why  some 
believe  that  phthisis  is  at  times  due  to  excessive  venery.  Lettule 
asserts  that  sexual  excesses  are  common  at  the  commencement  of  the 
disease  and  are  checked  only  when  the  limit  of  exhaustion  is  attained. 
W.  H.  Peters^  observed  a  tendency  to  abnormal  sexual  excitement  so 
frequent  among  consumptives  as  to  require  the  careful  attention  of  the 
physician.  He  also  says  that  "every  physician  has  been  impressed 
by  the  almost  disgusting,  and  sometimes  revolting  persistence  of  the 
sexual  instinct  in  consumptives,  even  late  in  the  disease." 

It  is  noteworthy  that  in  the  advanced  stages  of  the  disease,  when 
the  body  is  extremely  emaciated,  the  muscles  atrophied  and  the 
vital  forces  apparently  at  their  lowest,  sexual  potency  may  be  retained. 
Even  shortly  before  his  death  a  consumptive  may  impregnate  his  wife, 
and  a  woman  who  has  lost  half  her  normal  weight  and  is  subject  to 
frequent  hemorrhages,  runs  a  febrile  temperature,  sweats  and  coughs 
distressingly,  is  at  times  seen  in  a  pregnant  state.  Peters  quotes 
H.  L.  Barnes,  superintendent  of  the  Rhode  Island  Sanatorium,  about 
a  patient  who  died  from  a  hemorrhage  coming  during  the  sexual  act 
which  took  pkce  while  on  a  visit  from  the  sanatorium  to  his  wife.  I 
have  seen  several  somewhat  similar  cases.  In  hospitals  for  advanced 
consumptives  the  patients  must  be  watched  in  this  regard,  especially 
when  the  male  division  is  not  completely  separated  from  the  female 
division.  Sexual  excesses,  according  to  Gimbert,^  often  hasten  the 
fatal  outcome  of  the  disease. 

Other  ^Titers  deny  altogether  that  consumptives  are  more  sensuous 
than  others.  Karl  von  Ruck,^  in  a  review  of  the  subject,  arrives  at 
the  conclusion  that  "phthisis  is  not  a  cause  of  sexual  excesses,  there 
being  no  dift'erence  between  tuberculous  and  non-tuberculous  subjects; 
that  in  the  advancing  disease  the  sexual  functions  decline  the  same 
as  they  do  in  other  wasting  diseases."  But  the  bulk  of  the  evidence 
appears  to  favor  the  view  that  excesses  are  more  common  among 
consumptives  than  among  others. 

These  sexual  excesses  have  been  attributed  to  the  tuberculous 
toxemia,  but  others  have  denied  this  explanation.  It  has  been  stated 
that  the  lazy,  indolent  life,  the  lack  of  muscular  exercise,  and  the 
excessive  consumption  of  nitrogenous  food  during  the  treatment  are 
more  responsible  for  the  sexual  proclivities  than  the  tuberculous 
toxemia.    It  has  also  been  stated  that  in  sanatoriums  the  association 

1  Jour.  Amer.  Med.  Assn.,  1908,  1,  938. 

2  Revue  de  la  Tuberculosa,  1907,  iv,  1. 

3  Amer.  Jour.  Dermatology,  1907,  xi,  284. 


SEXUAL  IRRITABILITY  241 

of  the  sexes  favors  tendencies  in  this  direction.  In  many  the  despon- 
dency engendered  by  the  knowledge  of  suflFering  from  an  incurable 
disease  urges  the  patient  to  take  in  as  much  of  life  and  its  pleasures 
as  possible  before  it  is  too  late. 

There  are  other  chronic  diseases  in  which  the  patients  are  idle, 
eat  well  and  may  be  despondent,  yet  they  do  not  indulge  in  sexual 
excesses  to  the  same  extent  as  the  tuberculous,  which  would  be  in 
line  with  the  suggestion  that  the  tuberculous  toxemia  is  effective  in  the 
direction  of  causing  sexual  irritability.  Turban  found  that  in  artificial 
tuberculin  poisoning,  i.  e.,  when  tuberculin  is  administered  for  thera- 
peutic purposes,  sexual  irritability  is  increased,  and  in  some  cases  he 
had  to  discard  specific  treatment  for  this  reason.  "Every  physician 
with  a  large  experience  with  tuberculous  patients,"  says  Muralt, 
"knows  of  cases  in  which  recovery  from  the  disease  brought  about 
normal  functions  in  this  regard." 

Weygandt^  made  a  collective  investigation  of  this  problem  among 
physicians  in  German  sanatoriums  in  which  incipient  cases  are  ad- 
mitted. Many  of  the  answers  were  to  the  effect  that  they  had  not 
observed  any  special  increase  in  the  sexual  desires  of  their  patients; 
three  directors  of  sanatoriums,  Kohler,  Krause,  and  Marquard,  sent 
the  interesting  information  that  the  patients  had  accused  the  doctors 
of  secretely  putting  aphrodisiac  or  anaphrodisiac  drugs  into  the  milk 
or  other  food.  It  appears  that  in  many  German  sanatoriums  such 
superstitions  prevail,  thus  indicating  that  the  patients  themselves 
are  aware  of  the  increased  sexual  irritability. 

1  Mediz.  Klinik,  1912,  viii,  91  and  137. 


16 


CHAPTER  XIV. 
INSPECTION  AND  PALPATION. 

The  Stigmata  of  Phthisis. — After  the  history  and  symptomatology 
of  the  patient  have  been  carefully  inquired  into,  the  physical  examina- 
tion should  begin  with  inspection  of  the  physical  make-up  of  the 
individual.  In  phthisis  not  only  the  chest  should  be  carefully  examined 
but  also  the  head,  the  face,  the  neck,  the  abdomen,  and  the  extremities. 
The  stigmata  of  this  disease  are  often  scattered  over  various  parts 
of  the  body,  and  the  experienced  eye  may,  at  times,  find  outside  of 
the  region  of  the  chest  certain  signs  which  are  highly  suggestive  of 
phthisis.  In  some  borderland  cases  these  stigmata  may  be  of  great 
assistance  in  formulating  an  opinion  on  the  diagnosis  and  prognosis. 

Complexion. — Hippocrates  described  the  habitus  phthisicus- — the 
"form  of  the  body  peculiarly  subject  to  phthisical  complaints" — as 
characterized  by  a  smooth,  whitish  skin,  blue  eyes,  blond  or  reddish 
hair,  and  a  phlegmatic  temperament.  Following  this  ancient  clinician, 
many  modern  writers  on  this  subject  have  stated  that  the  external 
appearance  of  certain  persons  betrays  a  strong  predisposition  to  this 
disease. 

Hippocrates's  notion  that  blond-haired  and  blue-eyed  persons  are 
more  prone  to  phthisis  has  survived  to  this  very  day,  and  Beddoe, 
Landouzy,  Delpeuch,  Piery,  Woodruff,  and  many  others  hold  the 
same  view.  Exact  information,  however,  does  not  sustain  this  opinion 
that  fair-complexioned  people  are  more  prone  to  tuberculosis.  In 
countries  with  predominant  blond  populations,  like  Scandinavia, 
England,  Northern  Germany,  etc.,  the  consumptives  are  generally 
blonds;  while  in  Italy,  Spain,  Greece,  etc.,  where  the  dominant  racial 
elements  are  brunettes,  the  consumptives  are  of  the  same  complexion, 
as  can  be  seen  on  visiting  the  sanatoriums  in  these  countries.  In 
China  and  Japan  there  are  no  blonds,  yet  tuberculosis  is  not  lacking. 
Evidently  infection,  the  length  of  time  a  people  has  been  exposed  to 
the  tubercle  bacilli  and,  above  all,  social  and  economic  conditions  are 
of  greater  importance  in  determining  the  rates  of  morbidity  and  mor- 
tality than  race  or  color. 

Facies. — The  confirmed  consumptive  presents  a  characteristic,  in 
fact,  an  unmistakable  appearance,  which  betrays  his  disease  not  only 
to  the  experienced  physician,  but  also  to  the  laity,  and  he  can  often 
be  picked  out  from  a  group  of  healthy  people  with  coni]:)arative  ease 
and  certainty.  The  emaciated  l)()(ly,  the  pallor  of  the  face  with  the 
hectic  flush  on  the  cheeks,  the  roinid  shouhk^rs  and  the  bodily  decrepi- 
tude may  be  seen  in  other  wasting  diseases;  but  the  facies  of  the 


THE  STIGMATA   OF  PHTHISIS  243 

consumptive,  while  possessing  all  these  traits,  has  other  characteristic 
stigmata.  In  very  few  other  diseases  is  there  to  be  seen  such  a  typical 
facial  expression  as  in  the  consumptive. 

The  facial  muscles  are  wasted,  the  cheeks  sunken  and  the  malar 
bones  protrude;  the  lips  are  pale  or  livid,  often  contracted  as  if 
smiling  or  grinning;  the  hectic  flush,  which  may  be  unilateral;  the 
thin  neck  appears  longer  than  normal,  the  sternomastoids  are  accen- 
tuated like  two  tense  bands  on  both  sides;  the  head  is  bent  forward 
between  the  two  round  shoulders  and  the  spine  is  bent.  Because  of 
the  wasting,  the  ears  appear  larger;  one  may  be  redder  than  the  other. 

But  the  most  pathognomonic  parts  of  the  cast  of  countenance  of 
the  consumptive  are  his  eyes.  They  are  deeply  set  in  the  sockets, 
which  are  larger  than  normal  because  of  the  wasting  of  the  orbicularis 
palpebrarum.  We  also  meet  with  a  widening  of  the  palpebral  aperture 
and  a  slight  protrusion  of  the  eyeball  on  the  affected  side  as  a  result 
of  irritation  of  the  sympathetic.  A  narrow  palpebral  aperture  with 
a  somewhat  deeply  set  eyeball,  is  a  symptom  of  prolonged  irritation 
of  the  nerve  paths,  and  is  met  with  in  cases  with  adherent  apical 
pleura,  as  was  shown  by  Kuthy.  To  the  same  cause  has  been  attrib- 
uted unilateral  dilatation,  or  more  rarely,  contraction  of  the  pupil 
which  may  precede  the  evident  onset  of  active  disease. 

The  appearance  of  the  eye  as  a  whole  is  pathognomonic  and  can 
be  more  easily  recognized  than  described.  It  has  a  characteristic 
brilliancy  which  has  been  described  as  transparent,  lustrous,  bright, 
dimly  brilliant;  it  differs  from  the  brilliancy  of  the  eyes  in  other  fevers 
in  the  fact  that  it  appears  gloomy,  dismal  or  haunted — its  glance  can 
always  be  felt.  Some  have  attempted  to  explain  these  characteristics 
as  due  to  the  widely  dilated  pupils,  while  the  pearly-white  sclerotics- 
are  said  to  be  an  expression  of  vasomotor  succulence  of  the  bulbar 
conjunctiva  resulting  from  pressure  on  the  cervical  sympathetics  and 
are  to  be  seen  mostly  in  cases  of  adherent  apical  pleurisy. 

This  facies  has  been  recognized  by  the  laity,  and  the  folk-lore  of 
Europe  abounds  in  sayings  about  the  facial  expression  of  the  consump- 
tive. Writers  of  fiction  and  painters  have  also  considered  it  "inter- 
esting" and  make  great  use  of  it  in  their  productions.  Many  of  the 
classical  and  modern  painters  have  depicted  this  cast  of  countenance 
showing  the  false  euphoria  of  the  smiling,  tranquilly  bright,  yet 
melancholy  eyes  of  the  consumptive,  which  are  perhaps  best  seen 
in  Leonardo  da  Vinci's  La  Gioconda — a  picture  of  a  phthisical  face 
superior  to  any  description  that  can  be  given  of  it. 

I  have  seen  these  facies  in  some  patients  with  latent  or  quiescent 
tuberculosis  in  whom  physical  exploration  of  the  chest  showed  but 
indefinite  signs  of  a  lesion.  It  appears  to  be  especially  marked  in 
persons  of  phthisical  stock;  in  other  words,  those  who  were  infected 
during  childhood,  but  have  more  or  less  recovered. 

The  Skin. — Other  stigmata  of  phthisis,  which  may  be  noted  in  the 
early  stages  of  the  disease,  should  be  mentioned.    On  the  forehead  and 


244  INSPECTION  AND  PALPATION 

upper  parts  of  the  cheeks  we  may  see  cholasma  phthisicorum,  and,  in 
those  who  sweat  profusely,  pityriasis  versicolor  and  tabescentium  on 
the  anterior  and  posterior  aspects  of  the  chest.  In  those  who  suffer 
from  dyspnea  we  may  find  clubbed  fingers  or  deformities  of  the  hands, 
wrists,  spine  and  ankles,  which  are  the  results  of  pulmonary  osteo- 
arthropathy. On  the  neck,  spasm  or  atrophy  of  the  muscles,  which 
will  soon  be  described,  may  give  us  a  clue  that  a  careful  examination 
of  the  chest  is  indicated. 

Enlarged  Glands. — ^\^isibly  enlarged  glands  are  quite  rare  in  adults, 
though  I  have  seen  two  cases  in  which  they  went  on  to  suppuration. 
But  palpable  glands  on  the  neck  are  very  frequent — in  at  least  50  per 
cent,  of  my  cases.  In  children,  enlarged  glands  are  very  frequent, 
but  they  are  not  always  an  indication  of  tuberculosis.  If  enlarged 
cervical  glands  were  pathognomonic  of  tuberculosis  in  children  we 
should  find  very  few  who  live  in  poverty  free  from  this  disease  (see 
Chapter  XXIV) .  Of  greater  importance  from  the  diagnostic  standpoint 
is  enlargement  of  the  supraclavicular  glands,  especially  when  found 
unilateraUy,  and  it  speaks  for  tuberculosis  of  the  costal  pleura. 

We  also  very  often  find  enlargement  of  the  thjToid  gland  in  tuber- 
culous subjects,  at  times  in  the  incipient  stage.  The  reciprocal 
relation  between  hyperthyroidism  and  tuberculosis  is  a  mooted 
question. 

Enlarged  Veins  on  the  Chest. — Enlarged  veins  are  often  seen  on  the 
chest,  especially  in  the  infraclavicular  region  over  the  first  and  second 
interspace  and  posteriorly  opposite  the  first  thoracic  spine,  and  below 
along  the  line  of  insertion  of  the  diaphragm.  The  upper  enlarged  veins 
are  caused  by  the  interference  with  the  emptying  of  the  internal 
mammary  and  intercostal  veins  because  of  pressure  on  the  vena  azygus 
by  swollen  thoracic  glands,  and  also  by  the  increased  expiratory  efforts 
while  coughing.  They  are  occasionally  seen  in  healthy  persons,  espe- 
cially hi  nursing  women,  and  they  may  be  unilateral  in  patients  suffer- 
ing from  chronic  bronchitis  and  pulmonary  emphysema,  as  well  as 
with  endothoracic  tumors.  According  to  Lombardi,^  the  varicosities 
in  the  neighborhood  of  the  seventh  cervical  and  first  thoracic  vertebrse 
may  be  seen  in  80  to  90  per  cent,  of  cases  of  phthisis,  but  I  see  them 
very  frequently  in  persons  without  any  active  pulmonary  disease. 

It  will  also  be  noted  in  some  cases  that  the  nipple  is  lower  or  located 
more  externally,  while  in  women  the  mammary  gland  may  be  smaller 
and  the  nipple  may  be  less  pigmented  than  on  the  opposite  unaffected 
side. 

The  Phthisical  Chest. — Hippocrates,  Galen,  Aretaeus  and  other  ancient 
clinicians  mentioned  the  phthisical  chest,  and  modern  text-books 
devote  considerable  space  to  giving  details  about  its  form,  shape  and 
significance,  notwithstanding  the  fact  that  many  persons  with 
"phthisical  chests"  pass  through  life  unscathed,  while  many  consump- 

^  Gior.  intcinaz.  di  Scien.  med.,  1913,  xxxv,  751. 


THE  STIGMATA  OP  PHTHISIS  245 

tives  have  at  the  beginning  of  the  disease  excellent  chests.  There 
was  a  time  when  everyone  who  had  a  deformed  chest,  especially  of 
the  type  called  flat,  was  considered  tuberculous  or,  at  least,  predis- 
posed to  the  disease.  By  actual  measurement.  Woods  Hutchinson^ 
found  that  the  chest  of  the  consumptive  is  altogether  unusually 
round,  the  sternodorsal  diameter  is  comparatively  large  in  the  con- 
sumptive when  compared  with  the  average  healthy  person,  and  he 
suggests  that  it  is  due  to  a  persistence  of  the  infantile  thorax  in  the 
adult.  These  observations  have  been  confirmed  by  Bessesen,^  Niles 
and  others. 

The  problem  whether  the  phthisical  chest  is  a  cause,  congenital  or 
acquired,  of  tuberculosis,  has  also  been  raised.  As  will  be  shown  later, 
all  evidence  tends  to  show  that  it  is  an  expression  of  intrathoracic 
disease  and  thus  a  result  of  tuberculosis  during  childhood. 

The  Normal  Thorax. — Before  looking  for  the  pathological  chest  we 
must  have  a  clear  idea  as  to  what  constitutes  a  normal  thorax,  and  it 
should  be  stated  at  the  onset  that  a  well-formed  thorax  is  an  ideal 
which  cannot  be  encountered  more  often  than  a  perfectly  normal 
physique  in  the  individual.  I  can  do  no  better  than  quote  Pottenger's^ 
description,  which  is  as  complete  and  thorough  as  can  be  given: 

"Such  a  thorax  in  an  adult  should  be  symmetrical  on  both  sides. 
Beginning  at  the  clavicle  it  should  bulge  forward,  reaching  the  maxi- 
mum point  on  a  level  with  the  third  or  fourth  rib  and  then  gradually 
flatten  out  again  as  the  lower  border  of  the  ribs  is  reached.  The 
supraclavicular  and  infraclavicular  spaces  should  be  well  filled  and 
almost  even  with  the  clavicles  themselves.  The  scapulae  should 
stand  symmetrically;  the  ribs  and  intercostal  spaces  should  be  well 
covered  with  subcutaneous  tissue  and  muscles  so  that  the  intercostal 
spaces  are  barely  recognizable  in  the  upper  two-thirds  of  the  thorax, 
and  are  only  seen  distinctly  in  the  lower  portion  where  the  muscula- 
ture is  thin.  There  should  be  a  general  symmetry  in  the  muscles  of 
the  two  sides,  no  individual  or  group  of  muscles  standing  out  with 
undue  prominence  unless  it  be  those  that  are  increased  in  size  by 
greater  use,  such  as  the  deltoides,  trapezius,  rhomboides  and  pectorales 
in  persons  who  do  heavy  work  and  use  one  hand  more  than  the  other. 
The  anterior  neck  muscles  should  not  stand  out  unduly,  unless  the 
patient  is  emaciated.  Neither  should  the  neck  and  chest  muscles 
appear  degenerated  or  atrophied  under  normal  conditions." 

While  such  an  ideal  chest  is  only  rarely  seen  in  healthy  persons,  it 
is  never  seen  in  a  consumptive.  In  the  latter,  going  hand-in-hand 
with  the  progress  of  the  disease,  the  form  and  shape  of  the  thorax 
changes,  as  a  result  of  certain  changes  in  the  respiratory  muscles,  and 
in  many  cases  we  find  on  inspection  and  palpation  conditions  which 
are  characteristic  of  the  phthisical  chest. 

1  Jour.  Amer.  Med.  Assn.,  1903,  xl,  1196.  2  ibid.,  1905,  xlv,  2003. 

^  Muscle  Spasm  and  Degeneration  in  Intrathoracic  Inflammations,  St.  Louis,  1912, 
p.  15. 


246  INSPECTION  AND  PALPATION 

Technic  of  Inspection  and  Palpation  of  the  Chest. — In  addition  to 
the  light,  warm  room  and  stripping  the  patient  to  the  waist,  which 
are  seh'-evident  requirements,  the  patient  is  to  be  seated  on  a  round 
stool,  directly  facing  the  window  or  the  source  of  artificial  light.  He 
is  permitted  to  assume  his  natural  posture  without  urging  him  to  sit 
straight  up,  hold  his  head  in  the  middle  line,  etc.,  so  that  we  may 
note  any  faulty  position  of  the  head,  neck,  spine  and  chest.  Careful 
attention  is  to  be  paid  to  the  position  of  the  head,  the  shoulders,  the 
clavicles,  the  ribs  and  the  scapulae  during  rest  and  during  moderate 
and  forced  breathing. 

Above  all,  we  are  looking  for  evidences  of  asymmetry  in  structure, 
form  and  mobility,  when  the  two  sides  of  the  chest  are  compared. 
Motion  can  be  ascertained  by  inspection,  carefully  noting  from  a 
distance  the  tips  of  the  acromion  processes,  as  well  as  the  elevation 
of  the  ribs  during  inspiration,  the  position  of  the  scapulae  during  both 
phases  of  the  respiratory  act,  and  also  the  lateral  expansion  of  the 
lower  parts  of  the  thorax.  Flattening,  excavations  and  undue  promi- 
nence of  the  respiratory  muscles  are  to  be  especially  looked  for.  The 
supraspinous  and  supraclavicular  fossae  are  compared  and  any  devia- 
tion from  the  normal  should  not  be  overlooked.  Spinal  deformity, 
if  present,  must  be  given  attention  because  it  may  be  the  result  of  an 
intrathoracic  lesion,  and  also  because  it  may  have  an  immense  influence 
on  the  results  obtained  by  percussion  and  auscultation,  and  also  on 
the  skiagram. 

The  motion  of  the  anterior  aspect  of  the  thorax  is  best  studied  while 
standing  behind  the  patient  and  looking  over  his  head  watching  the 
ribs  and  clavicles  as  they  rise  and  descend  during  inspiration  and 
expiration,  and  noting  any  retardation  or  limitation  of  motion  on  one 
side  as  compared  with  the  other.  It  is,  however,  best  to  ascertain 
this  by  palpation,  placing  the  hands  on  each  side  of  the  patient's 
neck,  the  thumbs  meeting  behind  at  the  spine  and  fingers  reaching 
down  over  the  clavicles  (Fig.  39),  and  for  the  lower  parts  by  placing 
the  hands  over  the  lateral  aspects  of  the  chest.  In  this  manner  slight 
differences  can  be  detected  more  easily  than  by  inspection.  Special 
attention  is  to  be  paid  to  lagging — one  side  of  the  chest  is  delayed  in 
movement  and,  in  more  advanced  cases,  expansion  is  limited.  At 
times  we  meet  with  both  lagging  and  limitation  of  motion  in  various 
parts  of  the  chest  and  we  may  conclude  that  the  former  is  an  indica- 
tion of  a  recent  lesion,  while  the  latter  is  caused  by  an  old,  probably 
pleuritic  lesion. 

Spasm  and  degeneration  of  muscles  of  the  neck  and  chest  are  best 
ascertained  by  Pottenger's  method  of  "light  touch  palpation."  Press- 
ing the  tips  of  the  fingers  over  the  muscles  under  consideration  and 
moving  the  hand  sidewise,  carefully  noting  the  degree  of  resistance, 
will  show  this  condition.  While  doing  this  the  fingers  should  not  be 
allowed  to  slip  on  the  skin  because  it  is  the  condition  of  the  muscles 
and  not  of  the  skin  that  we  wish  to  ascertain.    Over  acute  lesions  it 


TECHNIC  OF  INSPECTION  AND  PALPATION  OF  CHEST   247 

is  found  that  the  muscles  give  to  the  palpating  fingers  a  distinct  feeling 
of  increased  resistance,  that  they  are  firmer  and  fuller  than  normal, 
while  over  advanced  lesions  there  is  a  flabby,  doughy  feeling  and  the 
bundles  can  be  easily  separated  owing  to  atrophy  and  degeneration. 

Significance  of  Lagging. — In  the  very  incipiency  of  a  pulmonary 
lesion  we  often  note  that  the  affected  side  of  the  chest  begins  to  expand 
and  the  shoulder  to  move  upward  later  than  the  opposite  healthy  side 
of  the  chest,  and  finally  does  not  attain  the  same  amount  of  expansion. 
In  far-advanced  cases  there  may  even  be  absolute  immobility  of  the 
affected  side.  It  is  best  ascertained  by  letting  the  patient  first  breathe 
normally  and  then  asking  him  to  take  a  few  deep  inspirations. 


Fig.  .39. — Testing  mobility  of  the  chest. 


Lagging  of  the  upper  part  of  one  side  of  the  chest  is  an  indication 
of  a  lesion  in  that  apex,  provided  an  acute  or  chronic  non-tuberculous 
inflammatory  process  of  the  lung  and  pleura  is  excluded.  When  the 
motions  of  both  sides  are  equal,  but  there  are  sure  signs  of  tuberculosis, 
we  may  conclude  that  there  is  a  bilateral  lesion.  With  an  old  quies- 
cent lesion  in  one  side  and  a  new  and  active  lesion  in  the  other,  the 
lagging  is  more  pronounced  in  the  newly  affected  side.  I  often  find 
difficulties  in  clearing  up  by  inspection  and  palpation  old  bilateral 
lesions  in  which  both  sides  show  limited  motion.  In  these  percussion 
and  auscultation  give  more  reliable  information.  But  in  incipient 
unilateral  cases  inspection  is  of  immense  value. 


248 


INSPECTION  AND  PALPATION 


Thoracic  Asymmetry. — Looking  at  the  phthisical  chest  anteriorly, 
in  cases  in  which  the  disease  has  already  made  some  inroads,  we  find 
some  undue  prominence,  even  arching  of  the  clavicle  and  more  or  less 
deep  excavation  in  the  supra-  and  infraclavicular  fossae,  more  marked 
or  exclusively  on  the  affected  side.  The  angle  of  Louis  at  the  junc- 
tion of  the  manubrium  and  the  gladiolus  is  more  pronounced  than  in 
the  average  healthy  chest.  Posteriorly,  we  find  kyphosis  in  many 
cases,  the  scapulae  are  prominent,  winged  and  even  dislocated,  nearer 
the  spine  on  the  afl^ected  side.  The  intercostal  spaces  are  rather  wide 
and  deep  and  in  extreme  cases  the  free  margins  of  the  costal  cartilages 
nearly  meet  in  the  middle  line.  In  addition  to  these  changes  we  meet 
with  distortions  of  various  parts  of  the  chest,  especially  the  upper 
half — flattening   and   retractions   of  various   degrees   anteriorly   and 


Sternocleidomastoid  m 

Scalems  post.m.^ 
Scalenus  med-in.^ 
Scalenus   ant.m 
Trapezius    m. 


Fiu.  40. — Muscles  of  the  neck  which  are  either  spasmodicallj-  contracted  or  atrophied 
in  pulmonary  tuberculosis. 

posteriorly.  Depression  of  the  acromial  end  of  the  clavicle  on  the 
affected  side  may  be  already  noted  in  the  very  early  stages  of  the 
disease.    Kuthy^  found  it  in  82  per  cent,  of  his  incipient  cases. 

Spasm  and  Degeneration  of  the  Thoracic  Muscles.— Any  or  most  of 
these  changes  in  the  contour  of  the  chest  may  be  noted  in  cases  of 
non-tuberculous  affections  of  the  thoracic  viscera,  and  also  in  patients 
who  had  a  tuberculous  lesion  which  had  healed,  the  patient  being 
in  excellent  health.  Pottenger,  in  his  epoch-making  studies  of  the 
tuberculous  chest,  has  given  us  certain  clues  as  to  the  means  of  differen- 
tiating these  conditions.  It  appears  that  intrathoracic  conditions 
have  a  great  influence  on  the  muscles  of  respiration,  a  fact  which 


1  Sixth  Internat.  Congr.  Tubcrc,  1908,  i,  1215. 


MUSCULAR  CHANGES  IN  ADVANCED  DISEASE  249 

has  been  known  for  a  long  time,  but  was  only  rationally  interpreted 
and  made  available  for  rational  diagnosis  by  Pottenger. 

Whenever  the  lung  or  pleura  is  acutely  inflamed,  the  thoracic 
muscles  over  the  seat  of  the  lesion  are  in  a  state  of  spasmodic  contrac- 
tion, like  the  abdominal  muscles  in  a  case  of  appendicitis.  Depending 
on  the  acuteness  of  the  inflammatory  process  in  the  pulmonary  paren- 
chyma or  pleura,  the  muscles  of  the  neck  and  chest  show  this  contrac- 
tion in  various  degrees. 

Inspection  and  palpation  reveal  this  condition  very  clearly  in  the 
vast  majority  of  cases.  Muscles  in  spasm  are  larger  and  firmer  in 
appearance  as  well  as  to  touch,  giving  a  distinct  feeling  of  increased 
tension.  Often  the  more  tendinous  parts  of  muscles  feel  like  distinct 
cords,  while  the  more  fleshy  parts  are  larger  and  firmer  to  the  touch 
than  normal  muscles  on  the  opposite  unaffected  side. 

After  the  inflammatory  process  in  the  lung  and  pleura  has  lasted 
for  some  time  and  passes  into  a  chronic  stage,  the  muscles  degen- 
erate; they  waste  and  become  flabby.  To  the  palpating  flnger  they 
feel  doughy,  their  normal  tone  or  elasticity  is  gone,  and  their  bundles 
are  easily  separated.  It  is  important  to  note  that  coincident  with 
this  change  in  the  muscles,  there  is  always  seen  atrophy  of  the  skin 
and  a  disappearance  of  the  subcutaneous  tissue.  Some  of  these  changes 
are  evident  to  the  sight  as  well  as  to  the  touch. 

Pottenger  looks  upon  these  muscle  changes  as  due  to  reflex  stimula- 
tion of  the  motor  nerves,  the  result  of  continuous  irritation  caused  by 
the  impulse  from  the  inflamed  lung  and  pleura.  When  this  irritation 
is  kept  up  very  long  degeneration  and  wasting  follow,  though  the 
latter  may  be  due  partly  to  trophic  disturbances.  But  if  it  is  true  that 
we  can  make  out  by  superficial  palpation  of  the  dead  body  internal 
solid  structures  it  would  indicate  that  the  theory  of  reflex  irritation 
is  inadequate. 

Muscular  Changes  in  Incipient  Cases. — In  incipient  cases  we  often 
find  that  the  sternocleidomastoid,  the  scaleni  and  pectoralis  anteriorly 
and  trapezius,  levator  anguli  scapuli,  etc.,  posteriorly,  are  in  a  state 
of  spasm:  They  stand  out  more  prominently,  are  larger  and  firmer 
to  the  touch  than  the  same  muscles  on  the  opposite,  unaffected  side. 
I  have  often  seen  that  as  a  result  of  this  spasm  the  supraspinous  fossa 
was  fuUer  at  first  sight.  When  occupational  influences  can  be 
excluded,  it  is  a  good  sign  of  active  incipient  phthisis.  W^hen  combined 
with  lagging  of  the  same  region  or  at  the  base  of  the  same  side,  it  is 
undoubtedly  a  sign  of  a  lesion  of  the  lung,  provided  non-tuberculous 
disease  can  be  excluded. 

Muscular  Changes  in  Advanced  Disease. — With  the  advance  of 
the  disease,  the  affected  muscles,  as  a  result  of  prolonged  spasm, 
begin  to  atrophy  and  degenerate.  The  result  is  that  on  inspection 
and  palpation  even  better  criteria  of  the  intrathoracic  condition  may 
be  elicited.  The  degeneration  of  the  skin  and  subcutaneous  tissue 
over  the  site  of  the  lesion  is  seen  at  once;  the  skin  can  be  lifted  up 


250 


INSPECTION  AND  PALPATION 


with  the  fingers  more  easily  and  it  is  felt  that  it  lacks  the  normal 
elasticity.  The  sternocleidomastoid,  scaleni,  pectoralis,  trapezius, 
levator  anguli  scapulae  and  rhomboidei  all  look  smaller  than  their 
mates  on  the  unaffected  side.  They  are  flabby  and  doughy  to  the 
touch. 

In  cases  with  old  circumscribed  lesions  limited  to  the  upper  part 
of  the  apex  we  may  find  the  upper  half  of  the  pectoralis  degenerated 


Fig.  41. — The  phthisical  chest.     Full-blooded  Indian.     (Musser.) 


and  flabby,  while  the  lower  half  is  normal.  As  a  result  of  atrophy  of 
the  trapezius  we  find  flattening  of  the  supraspinous  fossa;  in  extreme 
cases  it  appears  cupped.  In  old  cases  extension  of  the  flisease  may 
often  be  ascertained  by  inspection  and  palpation.  The  old  lesion  on 
one  side  shows  wasting  of  the  skin  and  muscles,  while  on  the  opposite 
side,  where  tubercles  have  just  caused  a  new  incipient  lesion,  the 
muscles  are  in  spasm — contracted  and  prominent.     Lagging  is  more 


MUSCULAR  CHANGES  IN  ADVANCED  DISEASE 


251 


pronounced  on  the  newly  affected  side;  it  indicates  an  active  lesion 
which  hinders  motion  of  the  contracted  muscles,  especially  the  dia- 
phrajj;m.  "When  palpation,  percussion  and  auscultation  show  evi- 
dences of  a  lesion  and  there  are  changes  in  the  mobility  of  the  suspected 
side  and  no  spasm  of  the  muscles  over  the  apex  but,  on  the  contrary, 
the  tone  of  the  overlying  muscles  has  decreased  and  there  are  evidences 


Fig.  42. — Emphysema  with  enlargement  of  the  chest;    the  anteroposterior  diameter  is 
much  increased.     (Musser.) 


of  atrophy  of  the  subcutaneous  tissue  combined  with  clinical  symp- 
toms of  tuberculosis,  we  are  justified  in  concluding  that  we  deal  with 
an  old,  inactive  or  healed  process."     (Pottenger.) 

In  many  cases  we  may  find  the  regional  muscles  more  or  less  atro- 
phied from  disuse,  especially  when  compared  with  the  opposite  side 
where  they  are  enlarged,  firm  and  prominent  because  of  excessive 
occupational  hypertrophy.     This  is  best  differentiated  by  bearing  in 


252  INSPECTION  AND  PALPATION 

mind  that  in  muscular  atrophy  due  to  disuse,  the  subcutaneous  tis- 
sue is  normal,  while  when  due  to  a  pulmonary  lesion  it  is  atrophied. 

Effects  of  Muscular  Atrophy  on  the  Thorax. — The  lagging  which  was 
formerly  attributed  to  lack  of  expansion  of  the  affected  lung  or  to 
pleural  adhesions,  is  better  explained  by  the  tonic  contraction  of  the 
scaleni  and  sternocleidomastoid  on  the  affected  side  which  raise  and 
fix  the  sternum  and  immobilize  to  a  certain  extent  the  first  and  second 
ribs,  thus  limiting  the  respiratory  motion  of  the  affected  side.  Round 
shoulders,  which  were  formerly  attributed  to  w^eakness  of  the  pos- 
terior muscles  which  hold  the  spine  erect,  are  more  rationally  explained 
by  Pottenger  as  due  in  a  great  measure  to  shortening  of  the  anterior 
muscles  through  spasm  and  degeneration,  together  with  lessened 
mobility  of, the  thorax.  Flattening  of  the  chest,  especially  over  pul- 
monary cavities,  which  was  formerly  attributed  to  atmospheric  pressure 
forcing  the  bony  thorax  to  contract  in  order  to  occupy  space  previously 
occupied  by  lung  tissue,  is  explained  by  Pottenger  as  due  to  inflam- 
matory disease  within  the  thoracic  cavity  and  reflex  interference  with 
the  normal  motion  of  the  diaphragm  which  is  kno"^ai  to  be  part  and 
parcel  of  phthisis  from  radiographic  studies. 

Bearing  in  mind  that  most  are  infected  with  tuberculosis  during 
childhood  but  that  the  pulmonarj^  lesion  heals  or  remains  latent,  it  is 
understood  that  the  lesions  produce  muscular  changes  in  the  manner 
described  above  during  the  time  of  their  activity.  Thus,  we  have 
an  explanation  for  the  origin  of  the  phthisical  or  paralj^tic  thorax. 
It  is  a  result  of  an  earlier  infection  which  has  healed  and  is  not  a  predis- 
posing cause  of  phthisis.  A  careful  study  of  children  of  tuberculous 
parentage  has  shown  that  they  are  born  with  normal  chests,  and  the 
characteristic  deformity  only  occurs  later  in  life  after  they  are  infected 
with  tubercle. 

Palpation  for  the  vocal  fremitus  is  of  no  diagnostic  value  in  any 
stage  of  phthisis,  excepting  in  cases  where  pleural  effusions  are  sus- 
pected. But  it  is  often  absent  in  thickened  pleura  and  thus  is  not  of 
assistance  in  our  attempts  at  differentiating  the  latter  from  an  effusion. 


CHAPTER  XV 
PERCUSSION  OF  THE  CHEST  IN  PHTHISIS. 

While  the  value  of  percussion  in  the  diagnosis  of  conditions  in  the 
advanced  stages  of  phthisis  and  its  complications  is  not  questioned,  it 
has  been  very  seriously  debated  whether  it  can  give  dependable  infor- 
mation in  the  early  or  incipient  stage.  Many  authorities,  notably  of 
the  French  school,  like  Grancher,  Bezangon,  Barbier,  Piery;  and 
also  S.  West,  Bonney,  Lawrason  Brown,  Henry  Sewall  and  others 
maintain  that  small  tuberculous  foci  in  the  lung  in  incipient  phthisis 
can  be  recognized  solely  through  recourse  to  auscultation,  and  that 
when  dulness  is  elicited  on  percussion  we  may  be  confident  that  we 
are  dealing  with  extensive  iiifiltration — a  more  or  less  advanced  stage 
of  the  disease.  On  the  other  hand,  Aufrecht,  Kronig,  Goldscheider, 
Ewart,  Lees,  Riviere,  and  many  others  maintain  that  if  we  are  to 
detect  incipient  lesions  in  phthisis,  we  must  resort  to  percussion  and 
it  is  only  when  the  process  has  advanced  that  definite  auscultatory 
signs  are  elicited. 

Aims  of  Percussion. — It  seems  that  these  differences  of  opinion 
are  mainly  due  to  a  misapprehension  as  to  the  aims  of  percussion. 
Those  who  expect  to  make  a  diagnosis  relying  solely  on  percussion 
findings  will  be  sadily  disappointed,  just  as  they  will  fail  in  attempt- 
ing to  draw  final  conclusions  from  any  other  single  symptom  or  sign. 
Percussion  only  gives  information  about  the  density  or  the  air  content 
of  the  lung  at  the  point  examined.  Whether  an  airless  area  thus 
detected  is  due  to  a  tuberculous  infiltration,  or  to  one  of  the  numerous 
other  factors  that  may  consolidate  large  or  small  areas  of  lung  tissue, 
must  be  determined  by  a  study  of  all  the  concomitant  symptoms  and 
signs.  On  the  other  hand,  given  symptoms  of  phthisis  such  as  cough, 
fever,  anorexia,  etc.,  signs  of  a  limited  infiltration  elicited  on  percus- 
sion may  enable  us  to  localize  the  process  and  complete  the  diagnosis 
in  the  absence  of  auscultatory  signs. 

We  must  bear  in  mind  that  phthisis  does  not  begin  as  a  catarrh  of 
the  small  bronchi,  as  some  believe,  but  as  an  infiltration,  transforming 
the  normal  porous,  air-containing  and  resonant  lung  into  solid  non- 
resonant  tissue.  At  this  stage  the  alveoli  are  filled  with  exudate,  or 
the  interstitial  tissues  contract  and  compress  the  alveoli,  finally 
obliterating  them  altogether.  Inasmuch  as  altered  breath  sounds  and 
rales  can  only  be  found  in  the  pulmonary  apices  when  edema  and 
secretions  interfere  with  the  entry  or  exit  of  the  air  current  while 
passing  through  the  air  vesicles  and  bronchioles,  it  is  clear  that  auscul- 


254 


PERCUSSION  OF  THE  CHEST  IN  PHTHISIS 


tation  may  not  give  any  information  at  a  very  early  stage.  As  long 
as  the  infiltration  remains  beneath  the  mucous  membrane  of  the 
bronchi,  the  entrance  of  air  into  the  alveoli  of  the  affected  area  is  not 
interfered  with  very  much,  while  in  the  rest  of  the  lung  it  is  freely 
circulating.  Auscultation  may  not  reveal  such  a  lesion  which  is 
surrounded  by  healthy  lung  tissue  working  vicariously  and  sucking 
in  more  air. 

It  is  only  when  the  caseous  material  of  the  infiltrate  softens  and 
breaks  through  the  wall  of  a  bronchus,  thus  permitting  the  entrance 


Fig.  43. — Outlines  of  viscera.     The  margins  of    the    lobes  of  the  lungs  are   shown 

(interrupted  line );    solid    black  line,  heart,  liver,  and  spleen;    stomach  shaded. 

(After  His-Spaltenholz,  Luschka,  and  Musser.) 

of  air  into  the  disease  focus  proper  that  rales  can  be  heard  on  auscul- 
tation. At  that  time  tubercle  bacilli  make  their  appearance  in  the 
sputum.  When  we  have  rales  we  may  be  sure  that  we  are  dealing  with 
a  more  or  less  advanced  stage  of  the  disease — caseation  and  softening 
have  already  taken  place. 

When  the  tuberculous  process  is  not  located  originally  in  the  bron- 
chioles, but  in  the  peribronchial  tissues,  it  is  again  evident  that  the  air 
circulating  in  the  bronchial  tree  cannot  reach  the  tubercle  at  all,  and 
the  auscultatory  signs  will  necessarily  be  negative.    At  most,  feeble 


TECHNIC  OF  PERCUSSION 


255 


or  absent  breath  sounds  over  a  limited  area  may  be  the  first  sign 
eHcited. 

Technic  of  Percussion. — Percussion  has  been  neglected  by  many 
because  it  has  not  given  them  the  information  they  sought;  at  times 
it  even  misinformed  them.  The  reason  is  almost  invariably  faulty 
technic.  Before  giving  details  as  to  percussion  findings  in  early 
phthisis,  we  must  speak  about  the  proper  technic  to  be  followed  in 
apical  percussion. 


Fig.   44. — ^Outlines  of   viscera.     The    margins  of  the    lobes  of    the   lungs  are    shown 

(interrupted  line );  solid  black  line,  heart,  liver,  and  spleen;  stomach  shaded. 

(After  His-Spaltenholz,  Luschka,  and  Musser.) 


The  first  and  most  important  point  is  a  light  stroke  with  the  finger. 
Heavy  blows  with  two  or  three  fingers  are  worse  than  useless.  Because 
of  the  elasticity  of  the  thoracic  walls,  a  great  part  of  the  percussion 
stroke  is  always  dissipated  along  the  muscular  and  bony  parieties,  and 
when  we  strike  a  heavy  blow  most  of  the  force  is  conducted  laterally 
by  the  ribs  and  intercostal  muscles,  which  are  set  into  strong  vibration, 
acting  as  large  pleximeters,  and  resonance  from  all  the  lung  beneath 
them  is  elicited.  Small  areas  of  airless  tissue  are  thus  overlooked. 
With  a  light  stroke  the  force  is  not  conducted  along  the  parieties,  but 


256 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


penetrates  sagitally  into  the  lung,  affording  information   about  its 
condition  immediately  beneath  the  point  examined. 


Fig.  45 


Fig.  46 


Figs.  45  and  46. — Margins  of  the  lungs  and  of  individual  lobes,  dotted  line  ( ) ; 

limits  of  pleural  sacks,  interrupted  line  ( );  liver  and  spleen,  solid  black  line; 

diaphragm,    starred   line    (******);   stomach   (portion  not  covered  by  lung)  shaded. 
(After  Luschka  and  Musser.) 

With  light  percussion  in  which  the  stroke  is  gentle  and  soft,  hardly 
audible  at  any  distance,  we  can  always  localize  areas  of  superficial 


TECH  NIC  OF  PERCUSSION  257 

dulness.  Deep-seated,  airless  areas  cannot  be  detected  by  heavy  per- 
cussion, as  is  evident  from  the  fact  that  we  cannot  map  out  the  heart 
from  behind,  and  in  obese  and  edematous  persons  it  is  quite  difficult, 
often  impossible,  to  define  the  boundary  between  the  liver  and  the 
lung.  Strong  blows  do  not  reach  much  deeper  into  the  pulmonary 
tissue  proper  than  light  strokes.  To  be  sure,  they  set  up  stronger 
vibrations,  but  mainly  in  a  lateral  direction  and  for  this  reason  the 
penetrating  power  of  the  heavy  blow  may  be  even  less  than  that  of 
the  light  stroke. 

Gentle  percussion  often  brings  out  small  areas  of  dulness  which  dis- 
appear with  an  increase  in  the  force  of  the  blow  because  larger  areas 
have  been  set  into  vibration.  This  point  is  utilized  for  diagnostic 
purposes :  If,  on  increasing  the  force  of  the  blow,  the  dulness  remains, 
we  may  be  sure  that  we  are  dealing  with  extensive  areas  of  airless 
tissue. 

The  Pleximeter  Finger. — Light  percussion  is  best  accomplished  when 
the  movement  of  the  percussing  finger  is  exerted  only  from  the  meta- 
.  carpophalangeal  joint.  The  note  elicited  should  be  only  a  faint  sound 
which  can  be  heard  when  listening  attentively.  Of  course  perfect 
silence  must  be  maintained  in  the  room.  When  reaching  an  airless 
area,  the  contrast  between  the  resonance  evoked  in  the  air-containing 
space  and  the  deadness  over  the  dull  area  is  striking.  It  has  been 
well  said  that  the  contrast  between  something  and  nothing  is  easier 
of  appreciation  than  the  difference  between  one  thing  and  another 
which  differs  but  slightly  from  it.  Over  resonant  areas  we  evoke  a 
note,  while  over  dull  areas  no  note  is  brought  out  at  all. 

Strong  pressure  of  the  pleximeter  finger  on  the  chest  wall  dissipates 
the  advantages  of  light  percussion  by  bringing  the  intercostal  muscles 
into  tension,  making  them  large  pleximeters,  which  elicits  resonance 
of  the  neighboring  air-containing  lung,  and  small  areas  of  dulness  can 
thus  not  be  delineated.  Very  light  contact  of  the  pleximeter  finger 
with  the  chest  wall  is  therefore  important;  in  delicate  percussion,  the 
mere  weight  of  the  finger  is  sufficient,  as  Sahli  points  out. 

Bearing  in  mind  that,  as  a  rule,  tuberculous  lesions  spread  from 
above  downward  and  that  the  line  between  the  healthy  and  infiltrated 
tissue  usually  runs  horizontally,  we  must  percuss  from  above  down- 
ward or  the  reverse  in  horizontal  zones.  The  pleximeter  finger  should 
be  placed  parallel  with  the  ribs  (Fig.  47)  and  not  perpendicular  to 
them  as  is  often  done.  It  is  obvious  that  when  the  pleximeter  finger 
is  placed  vertically  on  the  chest  we  obtain  mixed  resonance  because 
the  stroke  brings  both  healthy  and  diseased  lung  into  vibration  in 
cases  of  limited  lesions.  Only  intercostal  spaces  should  be  percussed 
because  percussion  of  the  ribs,  which  in  themselves  are  to  be  con- 
sidered as  long  pleximeters,  brings  out  resonance  due  to  vibrations  of 
large  areas  of  lung  tissue  which  lie  laterally  and  not  only  from  beneath 
the  spot  which  we  intend  to  strike  at  the  given  moment. 

The  usual  way  of  beginning  percussion  at  the  top  of  the  chest  and 
17 


258 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


going  gradually  downward  to  the  base  has  many  disadvantages.  It 
is  much  better  to  percuss  from  below  upward.  N.  K.  Wood^  sum- 
marizes the  reasons  for  this  procedure  as  follows :  "  It  is  much  easier 
for  the  ear  to  pick  up  a  higher  note  from  a  lower  than  it  is  to  do  the 
reverse;  it  requires  a  much  lighter  stroke  to  brmg  out  the  normal 
note  than  the  pathological;  it  is  the  rational  plan  to  work  from  the 
normal  as  a  standard  toward  the  pathological.  The  reverse  leads  to 
faulty  standards.  The  apices,  as  is  well  known,  are  most  frequently 
affected  and  more  rarely  give  a  normal  note.  To  start  at  the  apex, 
therefore,   is  usually  to  commence  with   a  pathological  note.     This 


Fig.  47. — Percussion  of  the  right  apex. 

prejudices  the  further  examination.  With  downward  percussion,  the 
higher  note  emerges  into  the  lower  too  imperceptibly  to  do  accurate 
work.  This  is  so  for  two  reasons:  (1)  the  mind  becomes  prejudiced  in 
favor  of  a  pathological  note  and  consequently  does  not  attempt  to  make 
fine  distinctions,  (2)  a  heavier  stroke  is  required  for  the  pathological 
note  and  when  the  more  resonant  is  reached,  the  percussion  is  con- 
tinued too  heavily  to  detect  what  should  be  readily  appreciated  differ- 
ences in  the  force  of  stroke  necessary  to  bring  out  a  good  note.  In 
this  way  the  examiner  deprives  himself  of  a  very  important  guide  to 
collect  accurate  data." 


1  Jour.  Amer.  Med.  Assn.,  1914,  Ixiii,  1378. 


TECHNIC  OF  PERCUSSION 


259 


The  Hooked-finger  Pleximeter. — In  incipient  phthisis  we  aim  at 
locahzing  the  smallest  possible  area  of  dulness,  and  at  times  the  plexi- 
meter finger  is  too  large  for  the  purpose.  Plesch^  has  suggested  that 
the  pleximeter  finger  be  flexed  at  the  second  phalanx  to  a  right  angle, 
the  pulp  is  only  applied  to  the  chest  and  distal  end  of  the  first  phalanx 
is  percussed  (Fig.  48).  This  maneuvre  also  enables  the  delimitation 
of  the  boundaries  of  the  apex,  or  the  determination  of  the  condition  of 
the  apex  behind  the  heads  of  the  sternocleidomastoid,  which  is  often 
of  great  importance. 

Position  of  the  Patient. — The  patient  should  sit  on  a  revolving  stool, 
or  better  stand  up  with  his  head  in  the  middle  line,  arms  hanging  by 
the  side  in  a  relaxed  condition  (Fig.  49).  Contraction  of  any  of  the 
muscles  of  the  chest  on  one  side  may  greatly  interfere  with  the  results. 
When  the  back  is  percussed  the  patient  is  asked  to  fold  his  arms  each 
on  the  opposite  shoulder  with  a  view  to  removing  the  scapulae  as  far 
outward  as  possible.     With  these  bones  in  the  normal  position  the 


Fig.  48. — -Hooked-finger  percussion. 

greater  part  of  the  lung  in  the  supraspinous  fosste  is  beyond  the 
bony  thorax  and  the  apex  is  partly  covered  by  the  shoulder-blades. 
To  hammer  away  in  the  supraspinous  fossae,  as  we  often  see  done,  is 
a  waste  of  time  and  energy,  because  percussion  there  strikes  bone  and 
thick  muscles,  and  the  waves,  hardly,  if  at  all,  penetrate  into  the  lung. 
But  with  folded  arms,  each  over  the  opposite  shoulder,  or  the  patient 
embracing  the  back  of  a  chair,  the  shoulder-blades  are  moved  far 
away  from  the  median  line  of  the  body,  thus  exposing  the  lung  covered 
by  comparatively  thin  parieties. 

When  it  is  desired  to  bring  out  the  finer  shades  of  resonance  or,  in 
doubtful  cases,  it  is  advisable  to  have  the  patient  lying  down  on  an 
upholstered  couch  or  an  examining  table.  Placing  the  patient  with  his 
back  near  a  wall  or  door,  or,  as  Lawrason  Brown  suggested,  standing 
in  the  angle  between  two  walls,  may  help  in  bringing  out  points  which 
might  otherwise  escape  attention. 


1  Munch,  med.  Wchnschr.,  1902,  xlix,  620. 


260 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


Fig.  49. — Percussion  of  the  left  apex  posteriorly. 


Fig.  50. — Hooked-finger  percussion  of  the  apex. 


Comparative  percussion 


261 


Comparative  Percussion. — When  percussing,  we  compare  sym- 
metrically corresponding  areas  on  both  sides  of  the  chest  and  percuss 
with  equal  force  while  striking  each  side.  This  is  especially  important 
because  there  is  no  standard  resonance  for  a  healthy  chest;  every 
individual  has  his  own  resonance  which  depends  on  many  factors, 
mainly  the  vibration  of  the  chest  walls  and  the  contents  of  the  thoracic 
cavity,  which  are  inconstant  values.  But  in  the  normal  chest  the  reso- 
nance, as  well  as  its  qualities  such  as  duration  and  pitch,  are  the  same 
on  both  sides.  The  slightly  impaired  resonance  over  the  upper  part 
of  the  right  side  may  be  disregarded  for  practical  purposes. 


Fig.  51.— Percussion  of  the  axilla. 

In  incipient  cases  there  are  "seats  of  election" — points  where 
dulness  is  most  likely  to  be  encountered  if  there  is  an  apical  lesion. 
Anteriorly,  it  is  mostly  under  the  inner  third  of  the  clavicle  and 
posteriorly  at  the  inner  margin  of  the  upper  half  of  the  scapula. 

A  small  area  of  defective  resonance  can  often  be  discovered  by 
immediate  percussion  directly  over  the  clavicle,  comparing  one  side 
with  the  other.  Immediately  above  and  below  the  clavicle  mediate 
percussion  will  bring  it  out,  if  it  is  present.  If,  on  light  percussion,  im- 
pairment of  resonance  is  discovered,  the  force  of  the  blow  is  dimin- 
ished to  a  minimum,  thus  delimiting  the  affected  area,  and  we  can  again 
percuss  the  same  spot,  gradually  increasing  the  force  of  the  blow, 
always  having  in  mind  the  thickness  of  the  integuments,  with  a  view 


262  PERCUSSION  OF  THE  CHEST  IN  PHTHISIS 

to  ascertaining  the  degree  of  dulness.  If  the  duhiess  disappears  with 
a  heavy  stroke,  the  lesion  is  of  sHght  extent  and  superficial,  or  there 
may  be  a  thickened  pleura;  })ut  if  it  persists,  we  may  feel  confident 
that  we  are  dealing  with  an  extensive  area  of  airless  tissue. 

Posteriorly,  we  look  for  dulness  over  the  apices  of  the  upper  and 
lower  lobes  of  the  lung.  The  former  is  located  in  the  supraspinous 
fossa  near  the  spine  and  reaches  the  first  thoracic  spine;  the  latter 
is  lower  in  the  right  side,  reaches  the  fourth  thoracic  spine  and  higher 
in  the  left  side  at  the  third  thoracic  spine  (Fig.  53).  If  impairment 
of  resonance  is  present  in  incipient  cases,  it  will  be  found  at  one  of 
these  four  points. 


Fig.  52. — Lung  margins  according  to  Goldscheider. 

While  doing  comparative  percussion  of  apices  it  is  imperative  to 
remember  that  in  the  majority  of  healthy  persons  the  resonance  over 
the  right  apex  above  the  third  rib  is  somewhat  defective,  the  note  is 
shorter  and  of  higher  pitch.  This  has  been  attributed  to  various 
causes.  The  recent  investigations  of  George  Fetterolf  and  George  W. 
Norris^  have  shown  that  it  is  due  to  the  anterior  position  of  the  large 
vessels  in  relation  to  the  right  apex,  as  compared  with  the  left ;  to  the 
consequent  encroachment  upon,  and  reduction  in  size  of,  the  right 
apex  and  to  the  contact  of  the  inner  surface  of  the  right  apex  with  the 
resonating  trachea,  while  the  left  is  in  contact  with  non-resonating 

1  Amer.  Jour.  Med.  Sci.,  1912,  cxliii,  637. 


TYMPANITIC  RESONANCE  IN  INCIPIENT  LESIONS        263 

solid  tissue.      In  right-sided  lesions,  when  the  signs  are  inconclusive, 
topographical  percussion  is  therefore  best. 

Tympanitic  Resonance  in  Incipient  Lesions. — ^In  the  early  stages 
the  absence  of  distinct  dulness  in  any  part  of  the  thorax  is  not  always 
an  indication  of  the  absence  of  tuberculous  infiltration.  Impair- 
ment of  resonance  can  only  be  brought  out  when  the  focus  is  at  least 
one  inch  in  diameter,  although  some,  like  Flint  and  Oestreich,  have 
detected  smaller  foci.  But  small  disseminated  tubercles,  before  they 
become  confluent,  may  alter  the  resonance  in  an  altogether  dift'erent 
direction.     Causing  relaxation  or  hyperf unction  of  the  surrounding 


Fig.  53. — Lung  margins  according  to  Goldscheider. 


lung  tissue,  they  impart  a  tympanitic  note  on  percussion.  This 
tympany  is  of  great  importance  in  the  diagnosis  of  incipient  lesions, 
and  is  usually  the  cause  why  two  competent  observers  will  at  times 
detect  the  lesion  on  different  sides  of  the  chest. 

Everyone  who  has  had  the  opportunities  and  inclination  to  watch 
incipient  tuberculous  lesions  has  met  with  cases  in  which  the  first  sign 
obtained  on  percussion  is  localized  tympany  which  subsequently 
changes  into  dulness  with  a  tympanitic  overnote,  and  finally  becomes 
dull.  Tympany  in  one  supraspinous  fossa,  when  accompanied  by 
suspicious  symptoms,  is  to  be  taken  seriously;  it  may  be  the  sole 
indication  of  small  disseminated  tubercles. 


264  PERCUSSION  OF  THE  CHEST  IN  PHTHISIS 

Absence  of  percussion  signs,  on  the  other  hand,  does  not  exclude 
incipient  phthisis,  because  the  lesion  may  be  located  deeply,  subapic- 
ally,  or  centrally,  or  it  may  be  altogether  a  more  malignant  process — 
miliary  or  disseminated  tubercles  all  over  the  lungs  which  have  not 
yet  become  confluent.  In  the  same  manner,  extensive  tympany  over 
one  lobe,  or  one  lung,  with  fever,  cough,  etc.,  may  be  an  indication  of 
extensive  tuberculization  of  the  affected  part.  The  outlook  is  not  as 
good  as  when  the  tubercles  are  localized  in  a  limited  area. 

Respiratory  Percussion. — -In  doubtful  cases  it  is  advisable  to  study 
the  changes  in  the  resonance  during  extreme  and  held  inspiration  and 
expiration,  as  was  suggested  by  J.  M.  Da  Costa^  forty  years  ago. 
He  showed  that  "at  the  apices,  and  especially  in  the  infraclavicular 
region,  in  the  supraspinous  fossse,  and  on  a  line  toward  the  spine,  a 
full  held  inspiration  increases  the  resonance,  makes  the  sound  fuller 
and  raises  the  pitch;  and  where,  as  is  so  common,  the  left  side  has 
normally  a  higher  pitch,  this  disparity  is  preserved."  A  held  and 
complete  expiration  will  greatly  lessen  the  resonance  and  lower  the 
pitch  at  the  apices.  "  In  the  held  inspiration  we  obtain  a  greater  mass 
of  tone;  in  held  expiration,  the  reverse."  This  change  of  resonance 
was  found  by  Da  Costa  to  remain  unaffected  in  bronchitis;  but  in 
phthisis,  even  in  the  earlier  stages,  the  affected  area  shows  the  reverse 
—a  long,  held  inspiration  gives  a  duller  note  than  that  observed  on 
the  healthy  side. 

This  change  of  note  during  held  inspiration  and  expiration  is  brought 
out  very  clearly  by  light  percussion  and  is  of  great  value  in  doubtful 
cases.  When  the  infiltration  increases  in  extent,  involving  the  larger 
part  of  the  apical  parenchyma,  the  dulness  on  percussion  is  no  longer 
modified  by  the  forced  and  held  expiration  and  inspiration.  Hence  we 
have  in  this  method  a  very  good  test  as  to  the  extent  of  involvement 
in  the  tuberculous  process.    Aufrecht^  confirmed  these  findings. 

Topographical  Percussion  of  the  Pulmonary  Apices.— There  are 
cases  of  incipient  phthisis  in  which  comparative  percussion  gives  no 
conclusive  information,  and  only  topographical  percussion — mapping 
out  the  limits  of  the  apical  resonance — may  clear  up  the  case.  This 
can  only  be  done  intelligently  when  we  have  clear  ideas  as  to  the  limits 
of  these  resonant  areas  in  the  healthy  person. 

Kronig^  showed  that  the  resonant  areas  project  as  cones  anteriorly 
and  posteriorly,  and  that  these  two  cones  are  united  on  the  top  of  the 
shoulders  by  a  narrow  strip  of  resonance — the  isthmus  (Figs.  54  and 
55).  With  careful  and  very  light  percussion  we  can  easily  map  out 
the  mesial  line  which  runs  in  front,  beginning  at  the  sternoclavicular 
articulation,  upward  and  outward  forming  a  concavity  inward,  while 
posteriorly  the  line  forms  a  convexity  and  ends  at  the  level  of  the  lower 
border  of  the  second  thoracic  spinous  process.    The  external  line  sep- 

1  Amer.  Jour.  Med.  Sci.,  1875,  Ixx,  17. 
2Berl.  klin.  Wchnschr.,  1912,  xlix,  101. 
5  Deutsche  Klinik.  1907,  xi,  581  and  G34. 


TOPOGRAPHICAL  PERCUSSION  OF  PULMONARY  APICES    265 

arating  the  resonant  apex  from  the  dull  shoulder  and  neck  runs  from 
the  middle  of  the  anterior  border  of  the  trapezius,  curving  downward 
and  reaching  the  clavicle  at  the  junction  of  the  middle  and  outer  third 
and  continuing  obliquely  downward  toward  the  axilla;  proceeding 
upward,  it  forms  a  convexity  toward  the  neck,  crossing  the  shoulders, 
on  the  top  of  which  it  is  separated  from  the  mesial  line  by  a  resonant 


Fig.  54 


Fig.  55 
Figs.  54  and  55. — Kronig's  apical  resonant  areas. 


space  of  about  2  to  3  cm.  forming  the  isthmus,  and  proceding  downward 
with  its  concavity  outward,  terminating  a  couple  of  centimeters 
outside  of  the  middle  line  of  the  scapula.  Normally  the  height  of  the 
apex  is  anteriorly  about  2  to  3  cm.  above  the  clavicle,  and  posteriorly, 
on  a  level  with  the  first  thoracic  spine,  about  2  cm.  outside  of  the 
middle  line  of  the  body. 

It  is  important  to  remember  that  the  pleximeter  finger  should  be 


266 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


applied  parallel  with  the  line  we  expect  to  delineate;  in  this  case  at 
right  angles  with  the  clavicle.  It  is  also  better  to  percuss  from  the 
lower  parts  of  the  chest  upward,  because  in  the  former  the  normal 
note  is  usually  found  in  early  cases  and  it  is  always  best  to  compare 
normal  resonance  with  defective  by  striking  the  former  first,  as  was 
already  indicated. 

Changes  in  Apical  Resonance  in  Phthisis. — When  the  resonant 
areas  are  marked  out  on  the  chest  of  a  healthy  person,  their  height 
and  width  are  practically  the  same  on  both  sides.  But  in  phthisis  one 
side  will  be  found  contracted.    Recalling  that  a  tuberculous  lesion  in 


Fig.  56.— Contraction  of  the  resonant  area  of  the  left  apex. 


the  apex  involves  shrinkage  of  the  pulmonary  parenchyma,  we  have 
an  explanation  for  this  phenomenon.  The  extent  of  the  shrinkage 
depends  on  many  factors,  mainly  the  degree  of  pulmonary  retraction 
and  the  location  of  the  lesion.  When  the  lesion  is  centrally  located, 
shrinkage  of  the  apex  is  greater  than  when  it  is  located  at  the  per- 
iphery or  under  the  pleura,  as  has  been  shown  by  Oestreich,  obviously 
because  in  the  former  case  traction  is  exerted  on  all  sides.  Autopsy 
findings  show  conclusively  that  this  shrinkage  occurs  quite  early, 
much  earlier  than  is  generally  appreciated  and  for  this  reason  we  may 
get  a  clear  view  as  to  the  condition  of  the  lung  in  that  region,  by 
percussing  the  apices  and  mapping  out  Kronig's  resonant  areas. 


CHANGES  IN  APICAL  RESONANCE  IN  PHTHISIS  207 


Fig.  57.— Kronig's  resonant  areas,  showing  a  band  of  doubtful,  or  relative  resonance 
at  the  mesial  border  of  the  left  apex;  also  retraction  of  the  lower  margin  of  the  left 
lung. 


Fig.  58. — Bands  of  doubtful  resonance  on  both  sides  of  the  right  apex  anteriorly. 


268 


PERCUSSION  OF  THE  CHEST  IN  PHTHISIS 


Shrinkage  manifests  itself  in  two  ways: 

1 .  By  a  narrowing  of  the  field  of  resonance  on  the  affected  side. 
This  can  be  established  by  actual  measurement.  The  isthmus  in 
healthy  persons  is  about  two  inches  in  w^idth,  and  when  we  find  it 
less  than  one  inch  in  width,  it  requires  investigation.  The  width  of 
the  base  of  the  resonant  cone  may  be  measured  simply  in  finger- 
breadths,  as  has  been  recommended  by  R=  N.  Philip.^  Both  sides 
are  to  be  of  the  same  width. 

2.  By  a  blurring  of  the  line  separating  the  resonant  from  the  dull 
parts  (Figs.  57  and  58).    While  in  health  we  can  easily  percuss  out  a 


Fig.  59. — Frequent  findings  with  Kronig's  method  of  percussion  in  advanced  cases. 
Retraction  of  the  left  lung. 


clear  line  of  demarcation,  in  tuberculous  apices  there  is  often  an  inter^'al 
in  which  the  resonance  is  doubtful.  This  is  mostly  found  at  the  inner 
outline,  but  may  be  found  at  both  sides.  Kronig  attributed  it  to 
changes  in  the  tension  of  apical  parenchyma  at  the  margin  of  the 
affected  parts.  These  points  are  better  illustrated  than  described 
(Fig.  59),  and  in  practice  after  the  outlines  of  the  apices  have  been 
marked  out  with  a  skin  pencil,  any  existing  differences  in  the  outlines 
of  the  apices  when  one  side  is  compared  with  the  other  are  noted  at 
a  glance  and  need  no  measuring. 

1  Edinburgh  Med.  Jour.,  1907,  xxii,  473. 


CHANGES  IN  APICAL  RESONANCE  IN  PHTHISIS 


269 


Sources  of  Error. — Kronig's  method  is  of  excellent  service  in  most 
cases  of  incipient  phthisis.  But  we  often  meet  with  cases  in  which 
after  careful  and  time-consuming  work,  the  results  attained  are 
unsatisfactory.  I  have  seen  cases  of  phthisis  in  which  no  dislocation 
of  any  of  the  outlines  of  the  apical  resonance  could  be  made  out. 
Then,  there  are  numerous  cases  in  which  contraction  of  the  apex  is 
made  out  very  nicely,  but  there  is  no  active  phthisis.  This  is  espe- 
cially true  of  "collapse  induration,"  which  will  be  discussed  later  on. 
Healed  tuberculous  lesions  also  leave  contracted  apices  and  what  we 
seek  to  determine  is  the  presence  of  active  phthisis. 


Fig.  60. — Same  patient  as  in  Fig.  .59;  findings  posteriorly. 


Kronig  stated  that  in  phthisis  the  motion  of  the  base  is  invariably 
affected  at  an  early  stage,  while  in  non-tuberculous  apical  lesions, 
the  expansion  of  the  lower  margins  of  the  lung  remains  normal.  This 
does  not  hold  in  practice.  There  are  many  cases  of  phthisis  in  which 
the  base  retains  its  normal  mobility  during  inspiration  and  expira- 
tion, and  the  reverse.  The  reason  for  the  occasional  failure  of  this 
method  of  percussion  lies  in  the  fact  that  the  resonant  area  is  not  an 
outline  of  the  true  anatomical  apex,  but  merely  a  projection  of  the 
same  lung  tissue  in  various  directions  (Figs.  61  and  62).  The  fact  is 
that  it  is  impossible  to  project  the  top  of  the  lung  on  the  surface  of  the 
body,  considering  its  peculiar  anatomical  position  and  form.  Kronig's 
isthmus,  for  instance,  does  not  exist  at  all,  and  we  must  remember 


270 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


that  only  the  mesial  border  corresponds  to  the  anatomical  margin  of 
the  lung  anteriorly  and  posteriorly.  The  lateral  border  cannot  be 
determined  with  exactness  in  most  cases  because  the  percussion  wave 
strikes  the  spot  tangentially.  In  patients  with  marked  scoliosis,  the 
method  is  of  no  value  at  all. 

Goldscheider's  Method  of  Apical  Percussion. — Anatomical  studies 
b}'  Goldscheider,^  as  well  as  orthodiagraphic  examination  of  the  lungs 
in  their  relation  to  the  bony  thorax,  show  conclusiveh'  that  there  is 


Fig.  61. — Showing  that  Kronig's  resonant  areas  are  not  outlines  of  the  apical  margins, 
but  are  merely  projections  of  the  same  lung  tissue  in  various  directions.  (After 
Goldscheider.) 

no  lung  tissue  in  most  of  the  resonant  area  percussed  out  by  Kronig's 
method.  Anteriorly,  the  apex  lies  beneath  the  two  heads  of  the  sterno- 
cleidomastoid, protruding  above  the  inner  third  of  the  clavicle  for 
about  one  inch  in  height.  This  is  seen  clinically  when  emaciated  per- 
sons cough  and  the  lung  is  blown  up  above  the  clavicle,  or  in  wasted 
infants  during  crying  spells.  Posteriorly,  the  apex  of  the  lung  lies 
close  to  the  spinal  column,  reaching  as  high  as  the  spinous  process 


'  Berl.  klin.  Wchnschr.,  1907,  xl,  1267  and  1309. 


GOLDSCHEIDER'S  METHOD  OF  APICAL  PERCUSSION      271 

of  the  first  thoracic  vertebra.  But  there  it  is  impossible  to  obtain 
resonance  from  it  because  it  is  covered  by  a  bony  transverse  process, 
rib  and  thick  muscles. 

Goldscheider/  for  these  anatomical  reasons,  devised  another  method 
of  obtaining  the  resonance  of  the  true  anatomical  apex,  Avhich  we  dis- 
cussed in  detail  elsewhere.^  From  the  complicated  procedure  of 
Goldscheider  all  that  is  of  utility  in  doubtful  cases  is  the  determina- 
tion of  the  height  of  the  apex  between  the  heads  of  the  sternocleido- 


FiG.  62. — Showing  that  KrSnig's  resonant  areas  are  not  outUnes  of  the  apical  margins, 
but  are  merely  projections  of  the  same  lung  tissue  in  various  directions.  In  the  supra- 
spinous fossEe  there  is  no  lung  tissue  at  all.     (After  Goldscheider.) 

mastoid,  which  can  easily  be  done  by  percussing  from  below  upward 
with  the  hooked  finger  as  a  pleximeter  and  comparing  the  two  sides. 
Posteriorly,  the  lung  resonance  should  reach  the  tip  of  the  spinous 
process  of  the  first  thoracic  vertebra  on  both  sides.  The  height  of  the 
apices  on  both  sides  normally  should  be  the  same  and  if  it  is  found 
shorter  on  one  side  it  demands  investigation  as  to  the  cause.  In  con- 
nection with  other  symptoms,  it  is  strongly  in  favor  of  tuberculosis. 


1  Ztschr.  f.  klin.  Medizin.,  1910,  Ixix,  205. 

2  New  York  Med.  Jour.,  1913,  xcvii,  799. 


272 


PERCUSSION  OF   THE  CHEST  IN  PHTHISIS 


Pottenger's  Views  on  Apical  Percussion. — There  remains  yet  to 
mention  that  Pottenger  sees  utiHty  in  apical  percussion  mainly  be- 
cause we  judge  not  only  the  resonance,  but  more  so  the  resistance  to 
the  pleximeter  finger.  When  there  is  an  active  and  recent  lesion 
in  an  apex  the  muscles  above  it  are  in  spasm  and  offer  greater  resist- 
ance than  normal  muscles.  He  points  out  that  when  there  is  defec- 
tive resonance  because  of  an  old  and  inactive  lesion,  the  muscles  are 
usually  atrophied  and  feel  soft  and  flabby  to  the  pleximeter  finger. 
Anteriorly,  the  sternocleidomastoid  and  scaleni  and,  posteriorly,  the 


Fig.  63. — Topography  of  the  apex  according  to  Goldscheider: upper  and  mesial 

borders  of  the  lung; borders  of  the  first  rib  and  clavicle.     On  the  left  side  the 

clavicular  head  of  the  sternocleidomastoid  has  been  removed  so  that  the  scalenus  anticus 
is  visible.    The  upper  border  of  the  lung  is  somewhat  higher  than  the  first  rib. 


trapezius  and  levator  anguli  scapulae  are  to  be  considered  in  this  con- 
nection. This  point  has  been  of  great  assistance  to  me.  Recently 
Galecki^  has  verified  it  in  a  very  thorough  study  of  the  subject. 

Tidal  Percussion. — After  ascertaining  the  limits  of  the  apices,  the 
base  is  to  be  delineated  with  a  view  to  determining  the  vertical  move- 
ments of  the  lung  in  the  pleural  sinus  during  both  phases  of  respira- 
tion. This  gives  us  information  as  to  the  presence  or  absence  of 
emphysema,  especially  in  fibroid  phthisis,  pleural  adhesions,  which 
are  of  such  immense  interest  when  thinking  of  applying  a  therapeutic 
pneumothorax,  etc. 

1  Beitr.  z.  Klinik  d.  Tuberkulose,  1914,  xxx,  363. 


SOURCES  OF  ERROR  IN  SIGNS  ELICITED  BY  PERCUSSION     273 

The  lower  margins  of  the  lung  resonance  are  first  ascertained  by 
percussion  while  the  patient  breathes  normally  and  quietly,  and  marked 
with  a  dermographic  pencil.  Then  the  patient  is  directed  to  take  a 
deep  breath  and  hold  it  as  long  as  possible  while  we  again  percuss 
and  ascertain  the  lower  limits  of  the  lung,  and  again  mark  them  with 
the  pencil.  In  healthy  persons  the  difference  in  these  two  lines  is 
between  one  and  two  and  a  half  inches.  It  is  to  be  borne  in  mind  that 
on  the  left  side  the  lung  margin  is  naturally  about  an  inch  lower  than 
on  the  right;  also  that  the  expansion  is  greater  in  the  axillary  line 
anteriorly  than  posteriorly.  In  emphysematous  subjects,  also  in 
the  senile,  and  in  those  with  deformed  chests,  expansion  may  be  very 
little  or  nil.  Pain  while  breathing  may  have  the  same  effect.  On 
the  left  side,  when  there  is  no  expansion  anteriorly  at  Traube's  semi- 
lunar space,  it  is  an  indication  of  pleural  adhesions,  or  effusion;  an 
increase  in  the  tympany  at  that  space  indicates  retraction  of  the  left 
lung,  not  infrequent  in  phthisis. 

In  most  cases  of  incipient  phthisis  the  respiratory  excursion  of  the 
affected  lung  is  more  or  less  restricted,  and  when  there  are  adhesions, 
there  is  unilateral  absence  of  respiratory  excursions.  But  since  we 
have  been  interested  in  pleural  adhesions  while  making  artificial 
pneumothorax,  we  find  that  these  signs  are  not  absolutely  reliable. 

Percussion  in  Advanced  Phthisis. — With  the  advance  of  the  disease 
the  percussion  findings  become  more  and  more  varied  and  scattered 
all  over  the  chest,  and  the  difficulties  of  determining  the  exact  condi- 
tion of  the  lungs  from  percussion  findings  alone,  more  and  more  unsur- 
mountable.  The  dulness  elicited  is  usually  due  not  only  to  the  active 
lesions,  but  also  to  such  as  have  healed  or  are  quiescent;  to  thickened 
pleura,  which  is  usually  a  conservative  process;  to  pleural  effusions, 
displacements  of  the  heart,  diaphragm,  liver,  stomach,  etc.  Some 
of  these  processes  are  permanent,  others  appear  for  a  short  time 
and  disappear  again.  Localized  emphysema,  transient  or  permanent, 
due  to  vicarious  function,  often  obscures  deeply  lying  airless  tissue. 

In  most  cases,  however,  we  find  that  one  lung  shows  dense  dul- 
ness in  its  upper  part,  usually  as  far  as  the  third  or  fourth  rib,  as  well 
as  retraction  of  one  or,  more  rarely,  both  bases.  But  even  this  may 
be  due  to  healed  or  quiescent  old  lesions.  We  also  find  a  frequent 
area  of  dulness  in  one  and,  at  times,  in  both  interscapular  spaces  due 
to  lesions  of  the  apices  of  the  lower  lobes,  or  enlarged  glands.  At 
times,  the  dulness  runs  along  the  lines  of  the  interlobar  fissures  ante- 
riorly and  posteriorly.  To  map  out  such  areas  of  dulness  may  be  of 
scientific  interest,  but  otherwise  the  diagnosis  of  these  cases  rests  on 
other  methods  of  exploration,  especially  the  subjective  symptoms. 
Signs  of  excavation  are  discussed  elsewhere.     (See  Chapter  XX.) 

Sources  of  Error  in  Signs  Elicited  by  Percussion.^When  finding 
defective  resonance  over  one  apex,  contraction  of  Kronig's  resonant 
area  on  one  side,  or  one  apex  shorter  than  the  other,  thus  indicating 
pulmonary  retraction,  are  we  justified  in  considering  the  patient  sick 
with  active  phthisis?  Are  differences  in  resonance  elicited  when  the 
18 


274  PERCUSSION  OF  THE  CHEST  IN  PHTHISIS 

two  sides  of  the  chest  are  symmetrically  and  comparatively  percussed, 
especially  in  its   upper  third,  sure  indications  of   active  phthisis? 

These  are  problems  that  confront  the  clinician  quite  often  and 
they  can  only  be  answered  by  an  intelligent  consideration  of  the  causes 
of  defective  resonance  and  dulness,  which  are  mainly  airless  lung 
tissue,  and  which  may  be  due  to  many  other  causes  in  addition  to 
tuberculosis.  Besides,  we  may  have  differences  in  the  resonance  due 
to  faulty  technic  in  percussion,  also  because  of  asymmetry  of  the 
chest  in  cases  of  kyphosis  or  scoliosis,  or  unilateral  hj^pertrophy  of 
the  muscles  due  to  occupational  effects.  These  factors  are  to  be 
eliminated  before  we  attempt  to  interpret  percussion  findings  in  early 
phthisis. 

There  are  other  sources  of  error.  Chronic  pneumonic  processes, 
healed  apical  lesions  and  pleurisy  are  very  common,  as  we  have 
already  shown,  and  many  leave  some  airless  tissue  which  is  detected 
by  careful  percussion.  So  that  even  if  due  to  tuberculosis,  apical 
dulness  or  retraction  does  not  always  mean  active  phthisis  requiring 
therapeutic  intervention.  Collapse  induration,  due  to  inhalation  of 
dust  in  mouth-breathers,  may  show  percussion  signs  which  are  undis- 
tinguishable  from  phthisis,  if  we  should  rely  on  percussion  alone. 
We  also  occasionally  find  dulness  in  the  apices  in  persons  leading 
a  sedentary  life  and  who  do  not  breathe  deeply,  especially  chlorotic 
girls.  Some  of  these  cases  are  cleared  up  by  directing  the  patient  to 
breathe  deeply  for  some  minutes,  or  practising  Da  Costa's  respiratory 
percussion. 

We  also  meet  now  and  then  with  persons  in  whom  the  resonance 
on  one  or  both  sides  of  the  chest  is  defective  without  any  excessive 
adiposity  or  strongly  developed  muscles  to  account  for  it.  The  air 
content  of  the  lungs  is  less  in  childhood  than  in  later  life,  and  it 
decreases  with  old  age,  often  without  showing  any  anatomical  changes 
in  the  lungs  at  the  autopsy. 

In  many  cases  a  study  of  the  overlying  muscles  as  to  rigidity 
and  atrophy  has  helped  me  immensely,  while  in  others  it  was  of  no 
avail. 

Diagnostic  Value  of  Percussion. — In  cases  presenting  symptoms 
of  phthisis  such  as  fever,  cough,  nightsweats,  etc.,  percussion  findings 
alone  are  often  sufiicient  to  localize  the  lesion,  and  in  many  cases  it 
will  be  found  by  prolonged  observation  that  a  lesion  develops  in  the 
apex  where  we  originally  found  only  defective  resonance  or  contrac- 
tion of  the  field  of  resonance,  though  auscultatory  signs  were  wanting. 

Percussion  findings  alone,  without  any  general  symptoms  of  phthisis, 
prove  nothing,  just  as  in  radiography  a  shadow  over  an  apex  does 
not  prove  an  active  tuberculous  lesion.  It  is  only  in  connection  with 
the  general  symptoms  that  percussion,  like  any  other  single  sign  or 
symptom,  can  be  utilized  for  diagnosis. 

However,  whenever  found,  defective  resonance  in  an  apex  demands 
careful  investigation  and  watching  of  the  case,  unless  a  reason  is  found 
for  its  existence. 


CHAPTER  XVI. 
AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS. 

'We  have  shown  that  percussion  is  a  most  valuable  diagnostic  method 
in  early  phthisis,  even  more  valuable  than  in  the  later  stages,  and  will 
often  give  definite  information  as  to  the  air  content  of  the  lungs  much 
earlier  than  other  methods.  Auscultation  is  just  as  valuable  for 
other  reasons.  At  times  it  affords  information  in  cases  in  which  the 
lesion  is  centrally  located  and  in  tuberculosis  grafted  on  an  emphy- 
sematous lung,  when  percussion  and  even  skiagraphy  may  fail. 
Similarly,  in  advanced  cases  where  the  lesion  is  extending,  altered 
br-eath  sounds  and  rales  may  often  be  found  in  advance  of  dulness. 
On  the  other  hand,  acute  cases,  especially  miliary  tuberculosis,  may 
show  normal  breath  sounds  and  no  rales,  and  in  chronic  cases  with 
deeply  lying  cavities  the  normal  lung  tissue  conceals  all  the  signs  of 
excavation.  In  the  former  diffuse  tympany,  while  in  the  latter  per- 
cussion or  radiography,  may  disclose  the  exact  state  of  affairs. 

Believing  that  the  technic  of  auscultation  is  much  easier  to  master 
than  that  of  percussion,  many  have  discarded  the  latter  and  rely 
solely  on  the  former,  which  is  a  grave  error.  The  fact  is  that  it  is  just 
as  difScult  to  acquire  skill  in  proper  auscultation  of  the  chest,  and  in 
interpreting  the  findings  correctly,  as  to  percuss  properly.  Some, 
like  Goldscheider^  and  Clive  Riviere,^  believe  that  auscultation  is 
even  more  difficult  to  master.  It  is  because  of  faulty  technic  that 
auscultation  does  not  yield  all  the  information  that  can  be  obtained 
by  this  method. 

Technic  of  Auscultation. — The  patient  should  be  stripped  to  the 
waist,  just  as  for  percussion,  and  seated  on  a  high  revolving  stool, 
so  as  to  be  accessible  from  all  sides.  Before  beginning  auscultation 
the  physician  must  assure  himself  that  the  patient  knows  how^  to 
breathe  properly  and  if  not,  which  is  very  often  the  case,  proper 
instruction  is  to  be  given  objectively.  One  important  drawback  to 
auscultation  is  that  many  patients  do  not  know  how  to  "expire" — 
they  just  inspire  jerkily  and  stop  with  inflated  chests.  Others, 
usually  such  as  have  led  a  sedentary  life  and  never  expanded  their 
chests  properly,  inspire  and  expire  quickly  and  in  rapid  succession 
so  that  it  is  difficult  to  follow  each  phase  of  respiration.  While  in  the 
vast  majority  a  little  instruction  suffices,  at  times  we  meet  with 
some,  and  not  exclusively  among  those  reputed  to  be  ignorant,  who 
will  not  breathe  properly  for  our  purposes,  especially  nervous  indi- 
viduals, and  the  examination  must  be  postponed  till  they  become 
accustomed  to  the  physician. 

'  Ztschr.  f.  klin.  Medizin.,  1910,  Ixix,  205. 

2  Early  Diagiaosis  of  Tubercle,  London,  1914,  p.  22. 


276  AUSCULTATION  OF   THE  CHEST  IN  PHTHISIS 

The  breathing  must  be  regular,  rhythmic,  somewhat  deeper  than 
usual,  and  through  the  nose,  because  when  the  air  enters  this  way  the 
lungs  expand  much  better  and  more  uniformly.  ]\Iouth-breathing 
occasionally  induces  cough.  In  cases  of  nasal  obstruction  the  patient 
breathes  through  his  mouth,  but  we  must  guard  against  noises  arising 
in  the  pharynx,  especially  those  created  by  the  soft  palate,  which 
impart  a  bronchial  or  blowing  character  to  the  breath  sounds  and, 
at  times,  give  an  impression  of  prolonged  expiratory  murmur,  when 
in  fact  there  is  nothing  of  the  kind. 

Special  attention  should  be  paid  to  expiration,  during  which  the 
patient  should  empty  his  chest  as  much  as  possible,  without  any 
undue  exertion,  and  that  each  expiration  should  promptly  be  followed 
by  a  deep  inspiration. 

Any  stethoscope  to  which  the  physician  is  accustomed  may  be 
used.  The  writer  prefers  the  Bowles  model.  The  bell  should  be 
applied  carefully  in  the  intercostal  spaces,  especially  in  emaciated 
persons,  so  that  it  makes  an  air-tight  connection  with  the  skin.  It 
should  be  held  firmly  but  without  any  undue  pressure,  thus  excluding 
all  extraneous  noises.  Movement  of  the  bell  of  the  stethoscope  upon 
the  surface  of  the  body  interferes  greatly  with  proper  auscultation 
and  should  be  avoided. 

Single  Phase  Auscultation. — To  appreciate  slight  changes  in  the 
duration  and  quality  of  the  respiratory  murmur  it  is  important  to 
listen  to  each  phase  of  the  respiratory  act  separately.  Grancher's^ 
method  has  served  me  best.  It  consists  in  first  listening  to  the  inspira- 
tory murmur  and  to  neglect  at  the  time  the  expiratory  murmur;  and 
when  listening  to  the  latter  the  former  is  to  be  neglected.  Rales  are 
always  looked  for  separately,  after  we  have  a  clear  idea  as  to  the 
character  of  the  breath  sounds. 

Beginning,  for  instance,  with  auscultation  of  the  left  apex,  we 
listen  attentively  to  the  inspiratory  murmur,  and  while  the  patient 
expires,  the  bell  of  the  stethoscope  is  quickly  carried  over  to  a  cor- 
responding point  on  the  right  side  of  the  chest  and  we  listen  to  an 
inspiration.  The  inspiratory  murmur  is  thus  compared  right  and 
left  and  any  differences  that  may  be  found  are  carefully  noted.  In 
this  manner  the  slightest  change  in  the  murmur  on  one  side  can  be 
best  appreciated,  because  we  have  a  standard  in  the  unaffected  side. 
Only  when  both  sides  of  the  chest  are  affected  is  this  method  unin- 
structive,  because  we  do  not  have  an  immediate  impression  of  a  normal 
inspiratory  murmur.  The  expiratory  murmur  is  to  be  studied  in  the 
same  manner,  carrying  over  the  bell  of  the  stethoscope  while  the 
patient  inspires,  and  noting  the  dift'erence.  While  listening  to  these 
murmurs,  no  attention  at  all  is  paid  to  any  adventitious  sounds  which 
may  be  present.     These  are  left  for  separate  study. 

This  method  of  auscultation,  devised  by  Grancher,  and  hardly  ever 

1  Maladies  de  Tapparcil  respiratoiro,  Paris,  IS'JO. 


FEEBLE  BREATHING  277 

mentioned  in  our  text-books,  is  the  only  one  that  can  bring  out  all  the 
changes  in  the  respiratory  murmurs  heard  in  really  incipient  pulmonary 
lesions,  and  should  be  used  exclusively. 

The  Normal  Respiratory  Murmurs, — The  most  important  prerequi- 
site of  proper  interpretation  of  auscultatory  findings  in  pathological 
conditions  of  the  lungs  is  a  knowledge  of,  and  experience  with,  the 
respiratory  murmurs  audible  in  normal  chests.  Without  this  knowl- 
edge we  cannot  expect  to  appreciate  slight  changes  audible  during 
either  phase  of  the  respiratory  act  in  early  phthisis.  It  is  because  of 
the  disregard  of  the  qualities  of  the  physiological  breath  sounds  that 
slight  changes  are  overlooked,  and  many  state  that  only  with  the 
appearance  of  adventitious  sounds  can  a  positive  diagnosis  be  made, 
which  is  decidedly  wrong,  just  as  is  waiting  for  tubercle  bacilli  to  make 
their  appearance  in  the  sputum.  One  who  wants  to  appreciate  the 
early  changes  of  phthisis  cannot  auscultate  normal  chests  too  often. 

The  physiological  or  vesicular  respiratory  murmur  shows  that  the 
pulmonary  parenchyma  at  the  auscultated  area  contains  air  which 
enters  with  each  act  of  inspiration,  and  leaves  with  each  act  of  expira- 
tion without  meeting  any  obstruction  in  its  course.  During  inspira- 
tion it  is  audible  with  different  degrees  of  intensity  ah  over  the  chest 
as  a  sighing,  whispering  rustle;  during  expiration  there  is  either  no 
murmur  at  all,  or,  more  commonly,  a  very  faint  noise  is  heard  which 
is  somewhat  lower  pitched  than  the  inspiratory  murmur,  notwith- 
standing thaf^Sspiration  actually  lasts  longer  than-Sspiration. 

Without  entering  into  the  problem  of  the  origin  of  these  murmurs, 
whether  they  are  produced  in  the  glottis  or  in  the  air  cells  in  the 
areas  under  examination,  we  want  to  emphasize  that  it  is  important 
to  bear  in  mind  while  auscultating  that  any  changes  in  pitch,  quality 
and  rhythm  noted  during  either  phase  of  respiration  are  to  be  given 
careful  attention  in  cases  in  which  early  phthisis  is  suspected. 

Feeble  Breathing. — When  meeting  a  patient  with  a  really  incipient 
lesion,  which  is  not  often  our  privilege  because  when  they  present 
themselves  the  lesion  is  usually  more  advanced  than  is  generally  appre- 
ciated, we  find  no  adventitious  sounds,  no  changes  in  the  type  of 
breathing,  no  bronchovesicular  or  bronchial  breathing,  etc.  The 
most  common  change  in  the  breath  sounds  at  this  stage  is  feeble 
breathing,  or,  more  rarely,  complete  absence  of  the  respiratory  mur- 
mur over  a  circumscribed  area  in  one  of  the  apices,  mostly  found 
posteriorly  near  or  above  the  spine  of  the  scapula,  the  zone  d'alarme 
of  Sergent,^  and  anteriorly  beneath  the  inner  third  of  the  clavicle. 
At  times  this  feeble  murmur  is  blowing  or  even  bronchial  in  character 
and  at  the  end  of  inspirations  some  dry  crackling  may  be  heard. 

To  be  of  diagnostic  significance  this  feeble  breathing  must  be 
localized  over  one  apex,  circumscribed,  fixed  and  persistent  for  some 
time,  and  uninfluenced  by  respiratory  efforts  and  cough.     It  is  an 

1  Le  Monde  Medical,  1912,  xxii,  1121;    La  Clinique,  1913,  viii,  437. 


278  AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS 

indication  of  peribronchial  tuberculous  infiltration  compressing  some 
bronchioles,  thus  creating  atelectasis  of  the  alveoli  they  supply;  or 
of  localized  pleurisy  interfering  with  the  respiratory  activity  of  the 
alveoli  in  the  affected  area. 

Localized  feeble  breath  sounds  are  also  found  over  healed  tuber- 
culous lesions,  or  adhesions  of  the  apical  pleura  following  abortive 
tuberculosis.  But  during  the  early  stage  of  active  phthisis  feeble 
breathing  accompanies  constitutional  symptoms,  such  as  cough, 
fever,  tachycardia,  etc.,  and  usually  some  signs  are  elicited  by  percus- 
sion of  the  same  area.  As  Bezan^on^  has  pointed  out,  in  the  absence 
of  constitutional  symptoms,  feeble  breathing  at  one  apex  is  a  sign  of 
a  healed  tuberculous  lesion. 

In  advanced  phthisis,  we  very  often  meet  with  limited  areas  of 
feeble  or  absent  breathing,  but  vigorous  cough  removes  the  plug  which 
obstructs  the  entry  of  air  into  a  bronchus  and  breath  sounds  are  again 
audible.  It  is  noteworthy  and  of  diagnostic  importance  that  atelec- 
tasis is  frequently  produced  by  plugging  of  a  bronchus  and  the  result- 
ing resorption  of  the  air  from  the  alveoli  may  produce  dulness  over 
the  area  supplied  by  that  bronchus,  but  no  breath  sounds,  no  adven- 
titious sounds  are  heard.  Occurring  at  the  base,  it  is  often  difficult 
to  distinguish  it  from  thickened  or  adherent  pleura  which  is  also 
characterized  by  feeble  or  absent  breathing,  as  is  pleural  exudate. 

In  acute  pneumonic  phthisis  I  have  repeatedly  met  feeble  breath 
sounds  in  addition  to  dulness  elicited  over  the  affected  lobe  of  the 
lung;  at  times  there  was  even  absence  of  all  breath  murmurs,  but 
some  moist  subcrepitant  rales  were  audible  over  the  same  region. 
Similarly,  we  may  meet  during  febrile  exacerbations  in  advanced 
cases,  with  feeble  breathing  over  newly  affected  areas,  which  later 
changes  into  bronchial  breathing,  etc. 

Rough  or  Granular  Breathing. — -This  is  often  found  in  incipient 
cases.  Here  again  it  is  the  inspiratory  murmur  that  is  especially 
affected :  It  is  dry,  rough,  low-pitched  and,  as  Minor^  describes  it,  it 
is  made  up  of  a  succession  of  very  short  sounds,  as  though  small, 
soft  granules  of  fine  wet  sago  were  being  rolled  over  each  other.  It 
should  not  be  confounded  with  puerile  or  harsh  breathing:  Granular 
breathing  may  be  altogether  diminished  in  intensity,  or  even  very 
faint,  while  puerile  breathing  is  always  intense  and  emphatically 
pure.  On  the  other  hand,  in  granular  breathing  there  is  always  a 
suspicion  that  adventitious  sounds  or  noises  are  superadding  the  inspi- 
ratory murmur.  According  to  Sahli,  it  is  a  sign  of  bronchial  catarrh; 
there  is  either  partial  impermeability  of  the  bronchi  producing  unequal 
respiratory  excursions  of  the  aftected  lung  area,  or  else  the  accompany- 
ing noises  are  derived  from  the  secretions  causing  partial  stenosis 
or  irregularity  in  the  lumen.  When  these  accompanying  noises  can 
be  plainly  isolated,  we  call  them  rales,  but  as  they  remain  indistinct 

1  Rev.  de  la  tuberculose,  1913,  x,  1. 

2  Klebs's  Tuberculosis,  p.  249. 


PROLONGED  EXPIRATION  279 

and  blended,  the  vesicular  breathing  becomes  impure,  granular  or 
rough.  It  is  generally  heard  over  the  supraspinous  fossse,  or  above 
and  beneath  the  clavicle. 

Grancher  insists  that  granular  breathing  is  a  sure  sign  of  incipient 
phthisis,  and  Clive  Riviere  speaks  of  it  as  the  earliest  auscultatory 
sign,  while  Piery^  says  that  it  is  nothing  of  the  kind,  but  that  it  is  a 
good  sign  of  a  cured  lesion  due  to  cicatrization  of  a  limited  area  of 
lung  tissue,  which  is  undoubtedly  a  fact.  I  have  seen  many  patients 
who  presented  granular  breathing  at  an  apex  for  years  without  show- 
ing any  of  the  constitutional  symptoms  of  phthisis.  On  the  other 
hand,  I  have  full  confidence  in  this  sign  when  there  are  the  usual 
general  symptoms  of  phthisis,  because  I  have  repeatedly  observed 
that  in  the  very  area  first  presenting  feeble  or  granular  breathing, 
there  subsequently  developed  typical  lesions  of  phthisis.  Of  course, 
one  must  always  bear  in  mind  that  the  absence  of  constitutional 
symptoms  is  an  indication  that  the  granular  breathing  is  probably 
due  to  a  cicatrix  remaining  after  a  tuberculous  lesion  has 
healed. 

Interrupted  or  Cog-wheel  Breathing. — The  respiration  saccadee  of 
the  French,  is  another  anomalous  type  of  breath  sounds  which  has 
for  a  long  time  been  considered  characteristic  of  early  phthisis.  The 
inspiratory  murmur  is  not  smooth  and  continuous  as  in  normal  respira- 
tion, but  is  broken,  so  that  it  appears  jerky,  divided  into  several  more 
or  less  distinct  parts.  It  differs  from  rough  breathing  by  the  fact  that 
each  portion  of  the  sound  retains  its  smooth,  rustling  character.  It 
is  apparently  caused  by  the  obstacles  met  by  the  air  current  while 
entering  the  alveoli.  The  breath  sounds  may  be  increased  or,  more 
commonly,  decreased  in  intensity. 

I  find  cog-wheel  respiration  only  rarely  a  sign  of  incipient  phthisis 
and  am  inclined  to  agree  with  Fiery  who  says  that  in  the  region  of 
the  apex  it  is  always  an  indication  of  pleural  adhesions  which  are 
often  the  remains  of  a  healed  tuberculous  lesion.  In  some  cases, 
however,  it  is  met  with  in  the  beginning  of  active  phthisis  and  the 
fact  that  in  the  later  stages  of  the  disease  it  can  very  often  be  heard 
along  the  borders  of  advancing  lesions,  shows  that  the  factors  produc- 
ing it  may  be  of  the  first  disturbances  of  the  respiratory  murmur  in 
the  areas  of  impaired  breathing  capacity  around  infiltrated  portions 
of  the  lung. 

Cog-wheel  breathing  is  occasionally  heard  over  chests  in  nervous 
patients  or  such  as  have  pains  due  to  acute  pleurisy,  or  who  shiver 
during  the  examination.  But  then  it  is  heard  all  over  the  chest,  while 
in  phthisis  it  is  localized  over  a  limited  area. 

Prolonged  Expiration. — From  what  has  been  stated  it  is  evident 
that  in  the  very  early  stages  of  phthisis,  auscultation  reveals  only 
changes  in  the  inspiratory  murmur,  a  point  which  cannot  be  too 

1  La  tuberculose  pulmonaire,  Paris,  1910,  p.  311. 


280  AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS 

strongly  emphasized.  In  older  books  on  the  subject  we  almost  always 
read  that  changes  in  the  expiratory  murmur  are  pathognomonic  of 
early  phthisis,  obviously  because  in  former  daj^s  incipient  phthisis, 
as  we  know  it  today,  was  not  recognized.  In  fact,  because  even 
today  patients  only  rarely  present  themselves  for  examination  at  the 
very  incipiency  of  the  disease,  we  usually  find  a  prolonged  expiratory 
murmur  at  the  first  examination.  But  speaking  as  one  who  has  had 
opportunities  for  examination  of  large  numbers  of  persons  who  do 
not  even  suspect  that  they  have  any  pulmonary  trouble,  and  examining 
the  lungs  of  everyone  who  comes  under  my  care,  I  find  that  changes 
in  the  inspiratory  murmur,  such  as  feeble  breath  sounds,  rough  or 
cog-wheel  breathing,  are  usually  found  earlier  than  changes  in  the 
expiratory  murmur. 

In  normal  vesicular  breathing  the  expiratory  murmur  is  either 
inaudible  or,  more  commonly,  it  lasts  only  one-fifth  to  one-fourth  the 
time  of  the  inspiratory  murmur.  When  it  lasts  as  long  as,  or  longer 
than,  the  inspiratory  murmur  it  is  undoubtedly  pathological,  though 
not  necessarily  of  tuberculous  origin.  When  audible  all  over  the  chest 
it  is  an  indication  of  bronchitis  or  pulmonary  emphysema,  but  when 
we  find  it  localized  at  one  apex,  its  significance  as  a  sign  of  phthisis 
is  to  be  appreciated.  It  may  be  due  to  sclerosis  of  a  limited  portion 
of  the  lung  tissue,  as  is  the  case  in  healed  tuberculous  lesions.  Indeed, 
when  it  also  has  a  bronchial  timber  it  is  pathognomonic  of  this  con- 
dition, and  Turban  speaks  of  it  as  "cicatricial  respiration." 

In  active  early  lesions,  prolonged  expiratory  murmur  localized  at 
an  apex  is  an  indication  of  either  catarrh  of  the  smaller  bronchioles, 
or  pressure  on  these  tubes  in  cases  in  which  infiltrations  produce 
stenosis.  It  is  therefore  usually  met  with  later  than  the  changes  in 
the  inspiratory  murmur,  of  which  we  spoke  above.  The  prolonged 
expiratory  murmur  is  often  harsh  and  rough,  and  with  the  advance 
of  the  disease  it  gradually  acquires  a  bronchial  character,  finally  becom- 
ing pure  bronchial  or  tubular  breathing.  While  we  may  meet  it  with- 
out any  adventitious  sounds,  this  is  exceptional  in  my  experience. 
On  the  other  hand,  it  may  be  feeble  and  hardly  audible  and  at  times 
we  hear  the  rales  very  clearly  while  the  prolonged  expiration  is  only 
detected  after  careful  listening. 

There  is  another  fact  to  be  borne  in  mind  while  evaluating  prolonged 
expiration  as  a  sign  of  early  phthisis.  Not  only  may  it  be  the  only 
indication  of  a  healed  lesion,  as  has  already  been  stated,  but  in  the 
right  apex  it  may  not  be  due  to  tuberculosis  at  all,  especially  in  young 
adults  with  thin  thoracic  walls.  In  collapse  induration  it  is  not 
uncommon,  while  in  persons  working  at  dusty  trades,  such  as  stone- 
cutters, carpenters,  miners,  garment-workers,  etc.,  the  expiratory 
murmur  at  the  right  apex  is  very  often  harsh,  rough  and  prolonged. 
Under  the  circumstances  it  is  of  more  significance  when  found  in  the 
left  apex,  and  in  the  right  side  a  careful  study  of  the  constitutional 
symptoms  must  be  made  before  attaching  any  diagnostic  value  to  it. 


BRONCHOVESICULAR  BREATHING  281 

Bronchial  Breathing. — With  the  advance  of  the  disease  the  dis- 
seminated tubercles  in  the  lung  conglomerate  by  growth  and  form  a 
sohd  circumscribed  mass  over  which  the  breath  sounds  elicited  on 
auscultation  are  more  or  less  characteristic.  The  vesicular  quality 
of  the  murmur  changes  by  degrees  till  it  finally  becomes  high-pitched, 
clear  and  blowing  during  both  inspiration  and  expiration,  which  is 
very  prolonged. 

Bronchial  breathing  is  a  sign  of  consolidation  of  lung  tissue:  The 
laryngotracheal  murmur  is  transmitted  and,  according  to  Sahli,  even 
magnified  M'hile  passing  from  the  bronchi  through  consolidated  lung 
tissue  to  the  surface.  It  is  thus  heard  over  areas  which  are  dull  on 
percussion,  particularly  over  the  upper  third  of  the  chest  anteriorly 
and  posteriorly.  During  the  course  of  chronic  phthisis  bronchial 
breathing  is  also  caused  by  many  complications  which  produce  com- 
pression of  the  alveoli  with  resulting  pulmonary  atelectasis,  as  is  the 
case  in  pleural  effusions,  pneumothorax,  hydrothorax,  etc.  In  these 
cases  the  bronchial  breathing  is  engendered  only  when  the  alveoli 
and,  at  most,  the  bronchioles  are  compressed;  when  the  large  tubes 
are  also  obliterated  by  compression  no  breath  sounds  at  all  are  audible. 

In  acute  phthisis,  bronchial  breathing  is  mainly  caused  by  caseous 
infiltration  of  the  affected  areas,  and  it  is  harsher,  louder  and  more 
high-pitched,  the  more  compact  and  extensive  the  consolidation  of 
lung  tissue.  Bronchial  breathing  in  phthisis  is  not  as  loud  and  reso- 
nating as  in  pneumonia,  and  when  it  is  encountered  it  is  an  indication 
of  an  acute  process  which  is  probably  progressive  and  of  serious 
prognostic  significance.  It  is  therefore  found  early  in  the  disease  in 
acute  pneumonic  phthisis  and  during  chronic  phthisis  over  the  seat  of 
new  extensions  of  the  process  involving  the  larger  part  of  a  lobe,  and 
in  the  terminal  stages  when  pneumonia  complicates  an  old  lesion  and 
carries  off  the  patient.  In  chronic  phthisis,  the  higher  the  pitch  of 
bronchial  breathing,  the  greater  the  consolidation  of  lung  tissue  which 
may  be  assumed. 

It  is  a  fact  to  be  remembered  that  in  the  average  case  of  chronic 
phthisis  bronchial  breathing  does  not  appear  suddenly,  but  by  slow 
degrees.  The  vesicular  murmur  is  gradually  transformed  into  broncho- 
vesicular,  which,  with  the  subsequent  consolidation  of  the  process, 
finally  becomes  purely  bronchial. 

Bronchovesicular  Breathing. — On  rare  occasions,  we  may  find 
bronchial  breathing  without  dulness  over  the  same  area;  in  fact,  I 
have  at  times  met  it  over  areas  emitting  tympanitic  resonance  on  per- 
cussion, which  is  an  indication  that  even  small  disseminated  tubercles, 
which  are  incapable  of  producing  dulness,  but  relax  the  lung  tissue 
and  cause  tympany,  may  cause  bronchial  breathing. 

But  usually  disseminated  tubercles  produce  bronchovesicular  breath- 
ing. We  hear  a  mixture  of  both  vesicular  and  bronchial  sounds  over 
the  same  area,  the  former  originating  in  the  small  consolidated  areas 
which  transmit  the  laryngotracheal  sounds,  while  the  latter  come  from 


282  AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS 

the  alveoli  of  the  unaffected  lung  tissue  that  surrounds  the  tubercles. 
It  is  thus  clear  that  the  presence  of  bronchovesicular  breathing  is  an 
indication  of  small  tubercles  scattered  within  normal  lung  tissue. 
This  is  usually  preceded  by  prolonged  expiration  which  changes  by 
degrees  into  bronchovesicular  breathing  and  finally  into  bronchial, 
as  has  already  been  shown. 

Sources  of  Error. — Bronchial  and  bronchovesicular  breathing  j)S'r  -^^ 
are  not  indications  of  phthisis.  In  addition  to  the  many  pathological 
conditions  which  may  cause  this  type  of  breath  sounds,  we  quite 
often  hear  it  over  healthy  chests.  There  are  many  individuals  in 
whom  bronchial  breathing  is  heard  all  over  the  upper  parts  of  the 
thorax.  In  the  interscapular,  right  supraspinous  and  supraclavicular 
spaces  it  is  very  common  in  apparently  healthy  persons,  especially 
during  vigorous  breathing.  This  is  said  by  Bandelier  and  Ropke  to 
be  found  in  about  one-third  of  healthy  people;  it  is  due  to  differences 
in  the  anatomical  structure  of  the  two  apices.  Fetterolf  and  Norris^ 
have  studied  these  differences  in  structure  in  detail  and  it  appears 
that  the  breath  sounds  have  better  opportunities  for  transmission 
to  the  surface  on  the  right  side  than  on  the  left.  In  addition,  because 
the  right  limg  has  three  main  bronchi,  it  favors  the  transmission  of 
bronchial  breathing  more  than  the  left,  which  has  only  two. 

Bronchial  breathing  is  very  common  in  these  locations  and  is  not 
to  be  given  undue  diagnostic  significance  unless  there  are  other  S}Tnp- 
toms  and  signs  of  phthisis.  Individuals  with  thin  thoracic  walls  are 
more  apt  to  show  this  sort  of  breath  sounds,  while  vigorous  breathing 
and  dyspnea  may  accentuate  it.  To  be  of  diagnostic  significance, 
bronchial  breathing  must  be  strictly  localized  over  a  limited  area  and 
accompanied  by  other  physical  signs,  especially  dulness  at  the  same 
spot. 

Another  source  of  error  in  auscultation  is  the  frequent  changes  we 
meet  in  the  respiratory  sounds  in  many  patients.  One  day  we  meet 
at  the  affected  area  bronchial  breathing  and  the  next  day  we  are 
surprised  by  vesicular,  or  feeble  breathing,  or  complete  absence  of 
breath  sounds  over  the  very  area  where  distinct  pathological  auscul- 
tatory phenomena  were  audible  the  day  before.  Vigorous  cough,  by 
removing  the  mucous  plug  in  some  tube,  may  reestablish  the  original 
sounds.  I  have  seen  such  changes  occurring  during  an  examination 
which  lasted  less  than  half  an  hour.  We  should  therefore  beware 
of  pronouncing  a  patient  free  from  changes  in  the  breath  sounds 
before  making  him  cough,  and  reexamining  the  chest  on  several 
different  days. 

Cavernous  and  amphoric  breathing  are  discussed  later  when  speak- 
ing of  pulmonary  excavations  and  of  pneumothorax. 

Adventitious  Sounds. — As  was  already  stated  while  speaking  of  the 
technic  of  auscultation,  adventitious  sounds  are  to  be  looked  for  only 

1  Amer.  Jour.  Med.  Sci.,  1912,  cxliii,  637;   Fetterolf,  Arch.  Intern.  Med.,  1909,  iii,  13. 


CREPITATION  283 

after  ascertaining  the  character  of  the  breath  sounds  during  each 
phase  of  the  respiratory  act.  To  pass  judgment  at  one  time  about 
both  breath  sounds  and  rales  is  hazardous  and  we  are  Hable  to  over- 
look many  important  points  which  are  of  diagnostic  and  prognostic 
significance. 

The  adventitious  sounds  audible  over  phthisical  chests  in  the  various 
stages  of  the  disease  are  manifold.  It  can  be  stated  that  all  kinds  of 
rales — sonorous,  sibilant,  crepitant,  subscreptitant,  gurgling,  etc. — - 
are  met  with  during  the  course  of  the  disease,  and  each  variety  has 
some  significance,  indicating  the  pathological  condition  of  the  lung. 
Paradoxical  though  it  may  seem  at  first  sight,  yet  it  is  a  fact  that  there 
is  no  rale  which  is  pathognomonic  of  phthisis,  nor  does  their  absence 
exclude  the  disease.  Especially  is  this  true  of  the  very  incipiency  of 
active  phthisis  which,  as  was  already  intimated,  begins  as  an  infil- 
tration and  not  as  a  catarrh  of  the  bronchi.  The  neoplastic  peri- 
bronchial formations  may  compress  the  alveoli;  the  proliferated 
interstitial  tissues  may  contract  and  obliterate  some  air  cells,  etc., 
but  such  processes  do  not  produce  rales  because  at  this  stage  the 
bronchi  are  not  flooded  with  fluid  or  semifluid  secretions  which 
could  interfere  with  the  entry  or  exit  of  air  through  the  bronchioles 
and  air  cells.  Moreover,  around  an  infiltrated  area  the  lung  usually 
acts  vicariously  and  thus  veils  any  alteration  in  the  breath  sounds 
that  may  be  created  in  the  diseased  focus  and  the  most  we  may 
expect  is  feeble,  harsh  or  cog-wheel  breathing,  but  no  rales. 

Rales  are  only  produced  when  the  caseous  material  softens  and 
breaks  through  the  walls  of  a  bronchus:  The  secretions  may  irritate 
the  bronchial  mucous  membrane  and  produce  a  catarrh  which,  in  its 
turn,  produces  more  secretion  which,  when  set  in  motion  by  the 
passing  air  stream,  engenders  rales.  This  is  a  fact  that  I  have  had 
many  opportunities  to  observe  in  patients  who  at  first  showed  only 
alterations  in  the  breath  sounds,  especially  weak  vesicular  murmur 
or  cog-wheel  breathing,  etc.,  but  no  rales,  in  spite  of  all  constitutional 
symptoms  of  phthisis  which  went  on  its  course,  and  only  later  adven- 
titious sounds  made  their  appearance.  In  such  cases  a  diagnosis  of 
phthisis  must  be  made  without  finding  any  rales.  In  fact,  I  have  met 
with  acute  cases  in  which  a  whole  lobe  was  infiltrated  in  a  compara- 
tively short  time;  percussion  showed  distinct  dulness,  auscultation 
disclosed  prolonged  expiration,  even  bronchial  breathing,  but  no 
rales  at  all  were  audible.  It  will  therefore  bear  repetition  that  waiting 
for  rales,  as  some  text-books  teach,  may  be  worse  than  waiting  for 
tubercle  bacilli  in  the  sputum  before  making  a  diagnosis. 

Crepitation. — With  the  onset  of  softening,  the  crepitant  and,  at 
times,  the  subcrepitant  rale  can  be  discovered  at  the  afi^ected  area. 
The  former  is  audible  exclusively  during  inspiration,  or  only  at  its 
end,  and  has  been  compared  to  the  sound  produced  by  rolling  one's 
hair  between  the  fingers  near  the  ear.  All  agree  that  this  rale  is  not 
caused  by  the  motion  of  fluid  secretions  in  the  small  bronchi  and  air 


284  AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS 

cells;  nor  by  the  explosion  of  air  bubbles  in  the  bronchi,  as  was  for- 
merly supposed.  The  consensus  of  opinion  appears  to  be  that  it  is 
caused  by  the  inspiratory  stream  of  air  tearing  apart  sticky  surfaces 
of  the  approximated  alveolar  walls,  though  many  hold  that  the  crepi- 
tant rale  is  altogether  a  friction  sound  produced  by  rubbing  of  the 
pleura  covered  with  tubercles,  as  was  first  suggested  by  Leaming.^ 
I  am  inclined  to  consider  them  purely  atelectatic  rales  analogous  to 
those  met  with  over  the  margins  of  healthy  lungs  in  persons  who 
breathe  superficially,  and  which  are  often  mistaken  for  crepitations. 

Crepitant  rales  are  usually  audible  during  quiet  breathing,  and 
provoked  by  vigorous  coughing  and  breathing.  ^Moreover,  they 
disappear  after  several  strong  efforts  at  deep  breathing,  which  would 
not  be  the  case  if  they  were  friction  sounds.  They  may  be  found 
early  in  the  morning  and  missed  throughout  the  day,  and  I  have 
seen  them  appear  and  disappear  within  half  an  hour  during  an 
examination.  At  times,  they  are  heard  at  a  very  early  stage  of  the 
disease  as  quite  numerous  cracklings  over  the  affected  area,  while  in 
other  cases  but  few  are  audible  and  they  are  spoken  of  as  "dry 
crackles,"  the  craquements  sees  of  French  authors. 

Crepitant  rales  are  not  by  any  means  pathognomonic  of  phthisis, 
for  reasons  already  stated,  but  when  audible  over  an  apex  showing 
contraction  of  Kronig's  resonant  areas,  or  impaired  resonance  in  a 
person  showing  some  of  the  important  constitutional  symptoms  of 
phthisis,  they  are  to  be  taken  seriously.  However,  in  order  to  evaluate 
them  properly,  we  must  carefully  study  them  with  particular  reference 
as  to  permanence  during  several  examinations  on  different  days  and 
that  cough  does  not  entirely  remove  them.  I  attach  greater  signifi- 
cance to  crepitant  rales  when  heard  over  the  supraspinous  fossa,  the 
alarm  zone  (see  p.  313)  than  when  heard  anteriorly  above  or  imme- 
diately below  the  clavicle,  because  in  the  latter  location  they  are  as 
often  spurious  as  real.  We  are  often  able  to  follow  them  up  to  the 
stage  when  they  become  moist — subcrepitant — and  finally  we  find  that 
signs  of  excavation  appear  at  the  same  spot. 

During  the  course  of  phthisis,  the  crepitant  rale  is  heard  quite 
often  around  the  seat  of  the  main  lesion,  indicating  that  the  process 
is  extending,  and  over  pneumonic  areas  so  often  caused  by  acute 
exacerbations.  In  unilateral  cases  in  which  the  other  side  is  second- 
arily implicated,  we  may  find  that  in  the  latter  the  first  audible 
adventitious  sounds  are  crepitations  and  these  secondary-  lesions  are 
worthy  of  study  by  those  who  want  to  be  able  to  recognize  and  eval- 
uate these  adventitious  sounds.  In  fact,  while  teaching  tuberculosis 
to  students,  advanced  cases  are  better  for  this  reason  than  early  cases 
in  which  the  diagnosis  is  often  doubtful. 

Moist  Rales. — ^With  the  advances  of  the  process,  softening  sets 
in    and   the   disintegrated   tubercles   are   eliminated  from  the  focus 

1  Diseases  of  the  Heart  and  Lungs,  New  York,  1884. 


SIBILANT  AND  SONOROUS  RALES  285 

through  the  bronchi,  to  be  finally  expectorated.  These  fluid  and 
semifluid  secretions,  while  remaining  at  the  site  of  the  lesion  and  in 
the  bronchi,  are  often  obstacles  to  the  entry  and  exit  of  the  air  current 
and  thus  produce  rales.  In  mild  cases  with  but  little  secretion,  we 
meet  with  the  high-pitched  subcrepitant  rales  produced  in  the  small 
bronchi.  When  softening  and  liquefaction  proceeds  and  the  secre- 
tions become  more  and  more  copious,  the  size  of  the  rales  increases 
and  we  hear  medium,  large  and  coarse  bubbling  rales  and  gurgles. 

The  difference  in  the  size  of  the  rales  apparently  depends  on  the 
difference  in  the  size  of  the  bronchi  in  which  they  originate — large 
bronchi  can  hold  larger  masses  of  fluid  and  mucous  secretion,  and  in 
smaller  tubes  less  secretions  are  moved,  while  in  excavations  the 
mass  of  secretion  may  be  very  large  and,  as  a  result,  we  get  gurgles. 
The  larger  rales  are  more  intense  and  louder,  though  of  a  lower  pitch 
than  the  smaller,  but  the  latter  are  usually  more  numerous,  evidently 
because  there  are  more  small  bronchi  than  large  ones.  Rales  are 
greater  in  number  and  more  consonating  when  originating  super- 
ficially, while  those  engendered  deeply  in  the  lung  may  not  be  heard 
at  all.  At  times,  we  can  hear  rales  in  central  lesions  by  placing  the 
bell  of  the  stethoscope  in  front  of  the  patient's  mouth,  while  all  over 
the  chest  nothing  is  audible. 

It  must  be  emphasized  that  no  rales  per  se  are  pathognomonic  of 
phthisis,  because  we  hear  more  adventitious  sounds  in  many  other 
conditions,  notably  bronchitis  and  bronchiectasis,  than  in  the  average 
case  of  chronic  phthisis.  To  be  of  significance,  the  rales  must  be 
strictly  localized  over  a  limited  area  and  persistent.  It  can  be  stated 
that,  excepting  in  far-advanced  cases,  or  the  rare  cases  of  chronic 
bronchitis  complicating  tuberculosis,  and  some  forms  of  fibroid  phthisis, 
the  larger  the  area  over  which  moist  rales  are  heard,  especially  bilater- 
ally, the  less  the  likelihood  of  their  being  of  tuberculous  origin;  the 
higher  up  in  the  chest  they  are  exclusively  audible,  the  more  likely 
that  they  spell  phthisis;  and,  when  heard  exclusively  at  the  bases  or 
over  the  lower  lobes,  the  chances  that  they  are  tuberculous  are  rather 
scanty.  Large  bubbling  rales,  when  heard  over  areas  where  there  are 
no  large  bronchi,  as  in  the  upper  third  of  the  chest,  are  of  greater 
significance  than  when  heard  over  areas  beneath  which  large  bronchi 
are  located.  The  latter  may  be  caused  by  bronchitis  or  bronchiectasis. 
When  large  bubbling  rales  are  heard  near  the  bell  of  the  stethoscope, 
they  are  indications  of  phthisical  excavation,  because  there  are  no 
large  bronchi  near  the  surface  of  the  lung. 

Sibilant  and  Sonorous  Rales. — These  are  very  often  heard  over 
tuberculous  foci.  In  many  incipient  cases,  especially  in  those  with 
stationary  or  healing  lesions,  whistling  and  snoring  rales  are  not  uncom- 
monly localized  over  one  apex,  especially  posteriorly.  When  not 
accompanied  by  crackles  we  may  take  them  as  an  indication  of  healing 
and  that  they  are  caused  by  the  compression  of  the  bronchioles  by 
fibrous  tissue  which  forms  during  the  process  of  repair.     Similarly, 


286  AUSCULTATION  OF  THE  CHEST  IN  PHTHISIS 

we  hear  sibilant  and  sonorous  rales  as  the  only  reminders  of  an  old 
and  cured  tuberculous  process.  In  senile  phthisis,  sibilant  and  sonorous 
rales  are  often  the  only  adventitious  sounds. 

The  asthmatic  forms  of  phthisis,  as  well  as  those  accompanied  by, 
or  implanted  on,  diffuse  bronchitis  and  pulmonary  emphysema,  espe- 
cially in  fibroid  phthisis,  often  manifest  themselves  by  sibilant  and 
musical  rales  heard  during  inspiration  and  expiration.  We  hear  all 
kinds  of  musical  notes,  snoring,  cooing,  whistling,  grunting,  groan- 
ing, whining,  etc.  They  may  be  heard  alone  while  the  respiratory 
murmur  is  feeble  or  inaudible,  and  then  they  may  also  be  accompanied 
by  all  kinds  of  moist  rales.  When  audible  all  over  both  sides  of  the 
chest,  the  diagnosis  of  tuberculosis  may  not  be  an  easy  task  and  dif- 
ferentiation from  chronic  bronchitis,  pulmonary  emphysema,  asthma, 
etc.,  can  only  be  made  after  considering  the  signs  revealed  by  percus- 
sion, as  well  as  by  the  constitutional  symptoms,  and  in  some  cases 
only  the  microscopic  findings  in  the  sputum  can  decide.  When  these 
sonorous  and  sibilant  rales  are  heard  unilaterally  they  are  easily  diag- 
nosed as  a  rule. 

Friction  Sounds. — These  are  very  often  heard  over  phthisical 
chests.  Over  the  apex  they  are  heard  best  anteriorly  above  and 
beneath  the  clavicle,  but  here  they  are  usually  not  very  distinct  because 
of  the  limitation  of  the  motion  of  the  lung  in  that  region.  Yet,  we 
sometimes  perceive  some  grating.  This  is  usually  very  difficult  to 
differentiate  from  crepitation — all  the  criteria  given  in  text-books 
are  futile  in  some  cases.  At  the  lower  parts  of  the  thorax  friction 
sounds  are  more  common,  especially  in  the  axillary  region.  On  rare 
occasions,  a  pleuropericardial  rub  is  heard  not  only  during  the  respira- 
tory phases,  but  also  synchronous  with  the  heart  beat.  It  is  an 
indication  of  dry  pleurisy  of  the  lingula  or  other  parts  of  the  pleura 
in  contact  with  the  pericardium. 

We  distinguish  friction  sounds  from  rales  b}"  the  fact  that  the 
former  are  heard  superficially,  right  near  the  bell  of  the  stethoscope; 
often  they  are  increased  by  pressure  of  the  stethoscope;  they  are 
uninfluenced  by  cough  which  usually  increases  the  intensity  of  rales 
or  entirely  removes  them;  they  are  annulled  when  the  breath  is  held. 
But  the  most  important  difterence  is  that  crepitant  rales  are  heard 
during  inspiration  only,  while  friction  sounds  are  audible  during  both 
phases  of  the  respiratory  act.  However,  in  many  cases  it  is  quite 
difficult  to  state  positively  wdiether  the  adventitious  sounds  under 
consideration  are  of  pulmonary  or  pleuritic  origin.  When  found  over 
an  extensive  area,  especially  posteriorly  or  in  the  axillary  region, 
frictions  may  be  diagnosed  by  assuming  that  rales  over  such  a  large 
area  would  represent  a  very  extensive  pulmonary  lesion  with  severe 
constitutional  symptoms,  while  pleurisy  may  persist  for  years  without 
impairing  the  general  condition  of  the  patient  very  much. 

Spurious  Rales. — Rales  of  extrapulmonary  origin  are  occasionally 
heard  while  auscultating  chests,  and  attributed  to  tuberculous  changes 


VOICE  SOUNDS  287 

in  the  lungs.  In  persons  suffering  nasal  obstruction  we  may  hear 
various  sounds  resembling  rales  which  disappear  when  the  patient  is 
made  to  breathe  through  the  mouth.  A  frequent  cause  of  extra- 
pulmonary rales  is  the  falling  back  of  the  tongue  when  the  patient 
makes  strong  efforts  to  breathe  deeply,  also  after  vigorous  coughing 
the  patient  swallows  and  we  believe  that  we  hear  rales  in  the  chest. 

Other  spurious  rales,  described  by  Peretz^  and  William  Ewart^  in 
England,  and  BushnelP  and  Hawes*  in  this  country,  are  caused  by 
muscular  contractions,  especially  the  trapezius,  and  on  raising  and 
lowering  the  shoulders  and  arms.  In  persons  who  lift  their  shoulders 
when  asked  to  breathe  deeply  these  "rales"  are  often  quite  audible. 
French  authors  speak  of  them  as  craquements  et  frottements  sousscapu- 
laires,  which  can  be  heard  very  often  over  the  upper  part  of  the  chest 
posteriorly.  These  muscle  sounds  were  a  potential  source  of  error  in 
9.2  per  cent,  of  250  cases  examined  by  Hawes,  while  joint  sounds  were 
found  in  22  per  cent,  of  cases. 

The  so-called  atelectatic  and  marginal  rales  are  even  more  often 
found  and  must  be  guarded  against.  They  are  mostly  heard  over 
the  anterior  and  lower  margins  of  the  lungs  and  are  probably  caused 
by  the  unfolding  of  collapsed  alveoli  in  individuals  who  breathe 
superficially  and  also  by  the  peeling  off  of  the  diaphragm  from  the 
chest  wall  as  the  lung  descends  into  the  complemental  space.  Richard 
C.  Cabot^  found  them  in  61  per  cent,  of  normal  chests  and  speaks  of 
them  as  of  crepitant  and  subcrepitant  varieties.  They  usually  disap- 
pear after  a  few  breaths,  but  at  times  they  persist  indefinitely. 

Bushnell  also  describes  sounds  originating  in  the  sternum  and  its 
articulations,  heard  particularly  at  the  second  costal  cartilage,  which 
may  lead  to  error,  and  I  have  been  able  to  verify  his  findings  in  a 
large  number  of  healthy  persons,  especially  muscular  men.  In  some 
cases  they  resemble  crepitation  and  occasionally  even  medium-sized 
moist  rales  and  clicks,  like  the  adventitious  sounds  of  early  phthisis. 
They  can  usually  be  differentiated  from  pulmonary  rales  by  the  fact 
that  they  are  localized  and  heard  loudest  over  the  sternum  and  its 
articulations,  but  in  doubtful  cases,  especially  those  showing  a  short 
note  at  one  apex,  they  may  lead  to  error. 

Voice  Sounds. — Bronchophony  adds  little  if  anything  to  the  infor- 
mation we  gain  by  percussion  and  auscultation.  It  is  generally  heard 
over  areas  which  are  dull  on  percussion  and  show  bronchial  breathing. 
Moreover,  it  is  necessary  that  the  pulmonary  consolidation  should 
be  superficial  in  order  to  produce  distinct  bronchophony  while  the 
breath  sounds  may  be  altered  with  moderately  deep  lesions.  Of 
course,  loud  transmission  of  the  voice  suggests  dense  pulmonary  con- 
solidation through  which  a  bronchus  is  passing,  while  decreased  voice 

1  Brit.  Med.  Jour.,  1896,  i,  82.  2  ibid.,  1912,  i,  771. 

3  Medical  Record,  1912,  Ixxxi,  101;    Ixxxii,  1109. 
*  Boston  Med.  and  Surg.  Jour.,  1914,  clxx,  153. 
6  Physical  Diagnosis,  New  York,  1909,  p.  163. 


288  AUSCULTATION  OF   THE  CHEST  IN  PHTHISIS 

sounds  indicate  pleural  effusions,  thickened  pleura,  emphysema  or 
even  thick  chest  walls;  in  short,  anything  that  diminishes  the  con- 
ductivity of  the  lung  and  intervenes  between  the  large  bronchi  and 
the  surface.  Even  a  plugged  bronchus  may  diminish  or  abolish  the 
voice  sounds,  which  reappear  after  several  vigorous  coughs. 

Bronchophony  is  very  loud  in  persons  with  thin  chest  walls,  or  who 
have  a  deep  voice;  and  in  general,  in  the  interscapular  space,  especially 
in  the  right  side,  for  obvious  reasons.  The  various  distinctions  of 
bronchophony,  pectoriloquy,  etc.,  have  no  significance  in  the  diagnosis 
of  phthisis. 

Whispered  Voice. — Of  greater  importance  is  the  auscultation  of  the 
whispered  voice.  In  this  it  is  really  not  the  voice  that  is  transmitted, 
but  the  breath  sounds  to  which  are  added  different  reverberations 
from  the  oral,  pharyngeal,  and  nasal  cavities.  My  experience  is  in 
agreement  with  that  of  Sewall  to  the  effect  that  in  auscultation  of 
the  whispered  voice  we  have  an  unrivalled  means  for  the  detection  of 
minute  changes  in  the  pulmonary  tissue.  I  have  been  able  to  outline 
consolidations  and  excavations  of  lung  tissue  by  carefully  studying 
the  whispered  voice,  and  other  methods  of  diagnosis  have  merely 
confirmed  the  findings.  Inasmuch  as  it  is  very  easy  to  acquire,  it 
ought  to  be  more  generally  adapted  in  the  routine  study  of  phthisis 
in  all  its  stages. 

We  must,  however,  remember  that  the  chest  walls  are  also  vibrating 
when  the  person  whispers  and,  especially,  when  he  talks,  as  has  been 
shown  by  Sewall.^  He  suggested  that  the  mural  vibrations  should 
be  damped  by  pressure  with  the  stethoscope,  and  thus  only  the  vis- 
ceral vibrations  will  be  brought  to  the  auscultating  ear.  He  shows 
that,  in  general,  it  may  be  said  that  with  the  intense  congestion  of 
the  lungs  or  such  tissue  changes  as  occur  in  early  phthisis,  the  voice 
takes  on  a  more  or  less  amphoric  or  tracheal  character  and  it  tends  to 
become  more  distinct,  prolonged,  raised  in  pitch,  and  nearer  the  ear 
with  pressure  of  the  stethoscope  on  the  surface  of  the  chest.  When 
the  patient  counts  "one,  two,  three,"  there  is  a  tendency  for  the  voice 
to  linger  with  a  bleating  echo  which  is  exaggerated  by  stethoscope 
pressure.  This  has  often  helped  me  in  doubtful  cases  in  which  both 
percussion  and  auscultation  were  absolutely  inadequate  to  justify 
a  final  opinion. 

Whispered  pectoriloquy  is  also  of  immense  value  in  patients  with 
laryngeal  involvement,  or  who  have  pleural  pains  and  cannot  breathe 
deeply,  and  especially  in  patients  soon  after  a  hemorrhage  when  we 
should  hesitate  in  going  through  all  the  diagnostic  maneuvers  which 
may  cause  the  bleeding  to  recur.  Whispered  pectoriloquy  and  bron- 
chophony and  auscultation  during  ordinary  breathing  can  give  us 
sufficient  information  to  form  an  opinion  on  the  extent  of  the  lesion. 

Over  healthy  lungs  the  whispered  voice  is  audible  in  the  upper  third 

1  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  2027;  Sewall  and  Childs,  Arch.  Intern.  Med., 
1912,  X,  45. 


VOICE  SOUNDS  289 

of  the  chest,  especially  on  the  right  side,  while  in  the  lower  parts  it 
is  hardly  or  not  at  all  audible.  An  increase  in  the  intensity  is  an  indi- 
cation of  better  sound  conduction — consolidation  or  compression  of 
pulmonary  parenchyma,  or  even  congestion,  as  has  already  been 
mentioned.  It  is  therefore  an  early  sign  of  phthisis.  It  must,  how- 
ever, be  borne  in  mind  that  it  is  heard  over  healed  lesions  and  there- 
fore is  not  to  be  taken  for  a  sign  of  activity  of  the  process  without 
confirmation  by  constitutional  symptoms. 

Over  air-filled  cavities,  pulmonary  or  pleural,  we  hear  what  Kuthy^ 
calls  "  amphorophony" — the  transmission  of  the  whispered  voice  with 
an  amphoric  or  metallic  echo.  It  is  an  indication  that  the  cavity  or 
pneumothorax  has  smooth  walls.  In  cases  with  cavities  we  can  at 
times  make  out  the  extent  of  the  excavation  by  auscultation  of  the 
whispered  voice  as  well  as  by  any  other  method. 

'  Die  Prognosenstellung  bei  der  Lungentuberkulose,  Berlin,  1914,  p.  302. 


19 


CHAPTER  XVII. 
SKIAGRAPHY  IN  THE  DIAGNOSIS  OF  PHTHISIS. 

Soon  after  the  introduction  of  the  a:-rays,  great  hopes  were  enter- 
tained that  finally  a  means  of  visualizing  the  condition  of  the  thoracic 
viscera  and  detecting  any  changes  in  the  lungs,  bronchi  and  pleura  had 
been  obtained.  But  after  several  years'  experience  it  was  found  that 
in  tuberculosis  skiagraphy  has  its  limitations,  just  as  other  diagnostic 
methods.  On  the  one  hand,  it  does  not  disclose  infiltrations,  the  very 
early  changes  in  phthisis;  on  the  other  hand,  because  it  clearly  shows 
caseated  and  calcified  foci,  revealing  airless  areas  of  lung  tissue,  it 
helps  in  establishing  an  anatomical  diagnosis.  Whether  the  changes 
discovered  are  tuberculous  in  character,  and  whether  the  lesion  is 
active,  must  be  ascertained  by  other  clinical  methods.  For  this  reason, 
skiagraphy,  while  a  very  important  aid  in  diagnosis,  cannot  be  relied 
on  to  the  exclusion  of  other  methods.  It  does  not  disclose  catarrhal 
conditions,  nor  does  it  reveal  infiltrations. 

When  properly  used  skiagraphy  helps  materially  in  discovering 
certain  changes  in  the  intrathoracic  viscera  which  formerly  escaped 
notice  during  the  life  of  the  patient.  Especially  is  this  true  of  deep- 
seated  lesions,  pleural  adhesions,  enlarged  bronchial  glands,  localized 
and  interlobar  effusions,  localized  pneumothorax,  small  cavities  in 
the  lungs,  the  motion  of  the  diaphragm,  abscess  and  gangrene  of  the 
lung,  etc. 

The  condition  of  the  lung  and  the  changes  at  the  site  of  the  lesion 
in  the  average  case  of  early  phthisis  can  be  made  out  easily  by  ausculta- 
tion and  percussion.  The  former  even  gives  important  indications 
as  to  the  activity  of  the  process  discovered.  But  the  .T-rays  complete 
the  examination,  and  often  reveal  deeper-lying  changes  in  the  chest 
which  otherwise  escape  detection.  Moreover,  the  practise  of  artificial 
pneumothorax,  which  has  lately  been  applied  with  such  strikins:  success 
in  proper  cases,  could  not  have  gained  general  acceptance  but  for 
skiagraphy. 

The  technic  of  x-ray  examination,  especially  the  comparative  value 
of  the  various  apparatus  employed,  will  not  be  discussed  here.  This 
is  the  province  of  specially  trained  technicians.  But  every  physician 
handling  tuberculous  cases  should  be  able  to  read  an  .r-ray  plate  and 
not  depend  entirely  on  the  specialist  radiographer  for  interpretation 
of  the  findings.  When  interpreted  in  connection  with  the  clinical 
symptoms,  with  which  the  physician  alone  is  acquainted,  the  .r-rays 
yield  the  best  results. 


APPEARANCE  OF  THE  NORMAL  CHEST 


291 


Appearance  of  the  Normal  Chest. — The  appearance  in  the  normal 
chest  should  be  known  before  attempting  to  decipher  pathological 
changes.  It  is,  however,  a  fact  that  a  normal  chest,  showing  no  signs 
suggestive  of  pathological  conditions,  is  exceedingly  rare.  I  have  not 
yet  seen  one.  Plate  III  shows  a  plate  from  a  chest  of  a  man  apparently 
free  from  pulmonary  disease. 

While  passing  through  the  thorax,  the  rays  are  obstructed  by  the 
various  tissues,  according  to  their  density,  volume  and  constituent 
elements,  and  the  result  is  that  the  denser  tissues  cast  shadows  on  the 
screen  or  plate.  The  densest  shadows  seen  are  that  of  the  heart  and 
great  vessels  in  the  middle  and  to  the  left,  and  the  diaphragm  beneath. 


Fig.  64. — Structures  making  up  the  hilus  shadow:  R,  second  rib;  W,  second  thoracic 
vertebra;  V,  arch  of  azygos  vein;  B,  bronchus;  L,  bronchial  lymphatic  glands;  A, 
aorta;    P,  pulmonary  artery;    0,  esophagus;    D,  thoracic  duct.     (Doyen.) 


Because  it  permits  the  rays  to  pass  with  less  resistance  than  any  other 
organ  in  the  chest,  the  lung  gives  a  dark  image  on  the  negative;  the 
heart,  the  large  vessels,  the  diaphragm  and  the  liver,  because  of  their 
density  and  blood  content,  obstruct  the  rays  and  produce  light  areas 
on  the  plate.  The  most  translucent  parts  of  the  healthy  viscera  are  the 
healthy  lungs,  but  when  they  are  collapsed  by  air  in  the  pleura,  as  in 
pneumothorax,  the  space  is  even  brighter.  In  healthy  persons,  when 
the  patient  takes  a  deep  inspiration,  the  lungs  brighten  up.  But  the 
brightness  of  the  lung  tissue  is  not  absolute.  There  is  seen  a  delicate, 
at  times  even  a  more  or  less  coarse,  arborization,  as  of  a  network 
passing  from  the  roots  of  the  lung  to  the  periphery.    At  the  roots  it 


292  SKIAGRAPHY  IN   THE  DIAGNOSIS  OF  PHTHISIS 

is  caused  by  the  greater  density  of  the  tissues,  but  in  most  persons 
also  by  the  deposition  of  carbon  particles,  which  may  be  found  in 
nearly  every  individual  over  fifteen  years  of  age.  When  the  shadow 
at  that  point  is  abnormally  accentuated,  it  may  be  an  indication  of 
enlargement  or  calcification  of  the  glands,  and  in  children  it  points 
to  tuberculous  tracheobronchial  adenopathy.  Often  we  note  in  this 
region  small,  sharply  defined,  oval  opacities  which  represent  optical 
sections  of  bloodvessels. 

It  is,  however,  difficult  or  impossible  to  evaluate  every  shadow  or 
opacity  because  by  their  passage  through  the  chest,  the  rays  are 
obstructed  by  the  various  parts  constituting  the  viscera,  thus  pro- 
ducing superimposed  shadows.  Carefully  prepared  stereoscopic 
pictures  may  enable  us  to  distinguish  these  superimposed  shadows 
in  perspective,  but  they  are  after  all  not  much  superior  to  a  good 
skiagram  taken  by  instantaneous  exposure.  The  excellent  studies  on 
the  subject  made  in  this  country  by  Dunham,  Boardman,  Wolman,^ 
Bibb  and  Gilliland,^  and  others  have  contributed  considerably  to  our 
knowledge  in  this  direction. 

The  Hilus  Shadow. — The  shadows  seen  at  both  sides  of  the  heart 
are  very  frequently  a  source  of  confusion  in  diagnosis.  As  will  be  seen 
from  Fig.  64  they  are  due  to  the  density  of  the  tissues  composing  the 
bronchi;  the  large  vessels  which  are  seen  either  in  transverse  or  in 
optical  section,  combined  with  the  opacities  produced  by  the  regional 
lymphatic  glands  and  connective  tissue,  none  of  which  can  be  difl^er- 
entiated  on  the  screen  or  plate.  While  in  some  cases  circumscribed 
opacities  or  spots  represent  calcified  glands  or  nodules,  in  others  they 
are  produced  by  deposits  of  dust  in  the  peribronchial  lymphatic  tissues 
which  are  very  frequent  in  adults,  and  even  in  children  in  cities  they 
are  not  uncommon.  But  in  many  cases  simple  engorgement  of  these 
tissues  with  blood  is  apt  to  give  a  shadow  in  that  region.  In  fact 
during  attacks  of  measles  or  whooping-cough  the  glands  in  the  chest 
have  been  found  visible  in  skiagraphic  plates,  and  the  same  is  often 
the  case  in  acute  affections  of  the  respiratory  tract  in  children  or 
adults. 

It  is  thus  clear  that  many  conditions,  other  than  tuberculosis  of 
the  tracheobronchial  glands,  may  cause  shadows  or  opacities  in  the 
hilus  region.  Moreover,  even  when  these  opacities  represent  anthra- 
cotic  or  calcareous  glands,  the  skiagram  alone  gives  us  no  clue  as  to 
the  activity  of  the  process,  which  is  after  all  the  main  problem  in 
clinical  diagnosis.  In  children  it  is  hazardous  to  diagnosticate  tracheo- 
bronchial adenopathy  because  of  these  opacities  when  the  clinical 
picture  is  not  in  agreement. 

To  the  right  side  of  the  heart  the  hilus  shadow  is  more  extensive 
than  to  the  left  because  in  the  latter  location  the  heart  shadow  obscures 
the  hilus  structures.     In  many  cases  we  sec  strands  i)assing  from  the 

1  Bull.  Johns  Hopkins  Hosp.,  1911,  xxii,  229. 

2  Arch,  Intern,  Med.,  1915,  xv,  588, 


FLUOROSCOPY  293 

hiliis  to  the  periphery  or  the  diaphragm.  It  is  the  consensus  of  opin- 
ion that  they  are  produced  by  bloodvessels  and  occasionally  by 
bronchi  which  at  times  appear  in  optical  section. 

Fluoroscopy. — An  x-ray  examination  of  the  chest  should  always  be 
preceded  by  a  fluoroscopic  examination  in  a  totally  dark  room.  In- 
asmuch as  this  is  very  difficult  to  attain  in  the  average  physician's 
office,  it  is  best  done  in  the  evening.  With  this  we  ascertain  the  shape 
of  the  thorax,  the  movements  of  the  ribs  and  diaphragm,  deformities 
of  the  bony  thorax  especially  the  spine,  etc.  In  the  healthy  person 
the  motion  of  the  ribs  is  symmetrical.  When  the  patient  takes  a  deep 
breath,  the  lungs  on  both  sides  light  up  to  the  same  degree.  Uni- 
lateral limitation  of  motion  of  the  ribs  is  suggestive  of  unilateral 
disease  and  phthisis  is  to  be  considered  in  this  connection.  When  we 
find  the  ribs  unduly  horizontal,  we  should  look  for  emphysema;  when 
the  horizontal  setting  is  unilateral,  pneumothorax  is  to  be  thought  of. 

Normally,  the  costal  cartilages,  especially  in  young  subjects,  are 
not  distinctly  visible  in  the  radiogram.  The  ribs  are  sharply  cut  off 
(Fig.  2,  Plate  III).  In  older  persons  they  are  usually  visible  owing 
to  ossification  which  takes  place  with  advancing  age.  In  tubercu- 
lous patients  ossification  of  the  costal  cartilages,  especially  the  first 
(Fig.  1,  Plate  VII),  is  very  frequently  seen  on  the  skiagram.  As  w^as 
already  stated  Freund  considers  this  a  predisposing  factor  to  phthisis 
because  of  the  stenosis  of  the  upper  aperture  of  the  thorax  which 
it  is  apt  to  cause.  In  some  cases  of  phthisis  all  the  costal  cartilages 
are  calcified,  and  when  examining  a  patient  with  the  x-rays  this  point 
should  not  be  neglected.  But  it  must  be  mentioned  that  it  is  not  an 
infallible  sign  of  active  phthisis.  It  may  be  found  in  persons  who  are 
not  sick,  while  I  have  repeatedly  found  cases  of  advanced  phthisis 
in  which  the  costal  cartilages  were  hardly  visible. 

The  apices  are  carefully  inspected,  and  the  translucency  of  the 
lungs  in  these  regions  inquired  into.  Theoretically,  it  should  be  of 
equal  intensity  on  both  sides,  but  such  perfection  is  only  rarely  en- 
countered, even  in  healthy  persons.  Usually,  owing  to  thickness  of 
the  muscles,  scoliosis,  etc.,  one  side  is  somewhat  darker.  But  this  is 
best  studied  on  the  skiagraphic  plate.  With  the  fluoroscope  we  look 
for  the  ''cough  phenomenon,"  first  described  by  Kreuzfuchs.^  This 
author  noted  that  in  healthy  individuals  the  translucency  of  the 
apices  varies  according  to  various  conditions,  especially  the  form  of  the 
chest.  Deep  respiratory  efforts  may  clear  up  any  shadow  in  healthy 
lungs.  During  cough  the  apices  brighten  up  even  when  they  are  other- 
wise quite  dark,  excepting  when  there  is  diseased  tissue  in  that  region 
and  the  affected  apex  remains  dark  even  during  cough. 

But  this  is  not  a  very  reliable  sign.  Jordan^  says:  ''Failure  of  the 
apex  to  light  up  is  difficult  to  make  out  with  certainty;  there  are 
endless  fallacies  due  to  the  position  of  the  x-ray  tube,  the  thickness 

1  Miinch.  med.  Wchnschr.,  1912,  lix,  80. 

2  Lancet,  1914,  i,  963. 


294  SKIAGRAPHY  IN  THE  DIAGNOSIS  OF  PHTHISIS 

of  the  pectoral  muscles  of  the'  patient,  the  '  lie'  of  the  ribs  and  clavicle, 
etc.,  and  at  best  it  is  almost  impossible  to  reproduce  this  'failure' 
on  a  photographic  plate  with  any  certainty.  I  am  quite  sure  that 
we  should  diagnose  pulmonary  tuberculosis  in  a  large  number  of  healthy 
subjects  if  we  are  to  rely  on  this  sign." 

This  view  is  shared  by  many,  but  it  appears  that  Jordan  is  mistaken 
in  his  statement  to  the  effect  that  the  cough  phenomenon  cannot  be 
reproduced  on  a  skiagraphic  plate.  As  will  be  noted  on  Plate  V, 
F.  Holst^  has  succeeded  in  reproducing  this  phenomenon  very  clearly. 
Moreover,  this  author  has  also  shown  that  during  cough  there  is  an 
alteration  in  the  lateral  limits  of  the  pulmonary  apices,  they  become 
wider  while  the  trachea  becomes  narrower,  sometimes  as  much  as  1  cm. 
In  normal  individuals  this  phenomenon  is  observed  on  both  sides  to 
the  same  degree,  while  in  case  one  apex  is  altered  by  tuberculous 
changes,  it  fails  to  brighten  up,  and  remains  narrow  and  darker  during 
cough.  Of  course  this  phenomenon  is  best  studied  on  the  screen, 
and  only  exceptionally  may  it  be  reproduced  on  a  skiagraphic  plate. 
We  must,  however,  guard  against  mistaking  the  apparent  changes 
in  the  brightness  of  the  apices  during  cough  caused  by  the  separation 
of  the  ribs  and  widening  of  the  intercostal  spaces.  It  has  been  of 
immense   service   to   me   in   many   cases. 

With  the  aid  of  fluoroscopy  we  also  ascertain  the  size  and  position 
of  the  heart.  In  phthisis  this  organ  is,  as  a  rule,  smaller  than  normal. 
In  fact,  when  I  find  a  large  heart  in  a  dubious  case  I  hesitate  before 
making  a  diagnosis  of  phthisis.  In  phthisis  it  is  also  very  often  ver- 
tical; it  may  be  "hanging"  cardioptosis,  and  in  more  advanced  cases 
frequently  displaced  toward  the  affected  side. 

After  the  apices,  the  diaphragm  should  claim  our  attention.  The 
mobility  of  this  muscle  has  been  found  defective  on  the  affected  side 
in  many  Cases  of  phthisis;  according  to  F.  H.  Williams,^  in  the  very 
incipient  stage.  The  motion  of  one-half  of  the  diaphragm  may 
not  only  be  delayed  when  there  is  a  pulmonary  lesion,  but  it  is  at 
times  seen  to  be  "jerky,"  or  "stammering,"  as  Harold  Mowat  says. 
In  some  healthy  persons  the  mobility  of  the  diaphragm  is  very 
limited,  while  in  most  the  breathing  excursion  is  from  three-fourths 
to  one  inch,  and  during  forced  respiration  it  may  even  move  more 
than  two  inches,  the  left  half  of  the  muscle  more  than  the  right. 
When  both  sides  are  stationary,  it  may  indicate  emphysema,  or 
nothing  at  all,  but  when  one  side  moves  while  the  other  is  immobile 
or  its  excursion  is  relatively  limited,  we  should  suspect  tuberculosis. 
Various  explanations  have  been  given  for  this  phenomenon.  Some 
have  attributed  it  to  diminished  power  of  retraction  of  the  lung, 
others  to  implication  of  the  terminal  branches  of  the  vagus,  or  of 
the  phrenic  nerve  in  the  apical  pleural  thickenings,  etc.  In  advanced 
cases  limitation  of  motion  may  be  due  to  pleural  adhesions.    It  must 

1  Miinch.  med.  Wchnschr.,  1912,  lix,  1659. 

2  Amer.  Jour.  Med.  Sci.,  1897,  cxiv,  655. 


SKIAGRAPHY  295 

however,  be  emphasized  that  in  itself  defective  movement  of  the 
diaphragm  may  be  found  in  healthy  individuals.  If  unilateral  it  may 
be  due  to  paresis  of  that  muscle,  or  to  an  old  basal  pleurisy  producing 
adhesions  which  hinder  its  excursion.  In  persons  with  big  abdomens, 
the  breathing  is  usually  purely  thoracic,  and  the  diaphragm  is  immobile. 

Extensive  experience  has  shown  limitation  of  motion  on  the  affected 
side  of  the  diaphragm  in  only  a  few  cases  of  incipient  phthisis.  Indeed, 
we  often  see  advanced  cases  in  which  both  sides  of  the  diaphragm 
are  freely  and  equally  mobile.  On  the  other  hand,  limitation  is  found 
in  non-tuberculous  cases  owing  to  adhesions  remaining  after  previous 
attacks  of  pleurisy.  In  advanced  cases  this  phenomenon  has  been 
considered  in  connection  with  the  feasibility  of  artificial  pneumothorax, 
but,  as  will  be  shown  later  on,  it  is  not  absolutely  reliable. 

In  many  cases  we  can  diagnosticate  diaphragmatic  pleurisy  by  the 
marked  elevation  of  the  curve  during  inspiration;  in  others  we  note 
a  series  of  small  irregularities  in  the  contour;  in  still  others,  bands  of 
connective  tissue  are  seen  passing  from  the  diaphragm  to  the  lung. 

Skiagraphy. — Of  greater  value  in  all  stages  of  phthisis,  especially 
in  dubious  early  cases,  is  radiography.  When  properly  taken  and 
developed,  the  plate  may  be  studied  at  leisure  and  slight  alterations, 
which  are  not  visible  on  the  fluoroscopic  screen,  may  be  easily  detected. 

In  evaluating  the  skiagraphic  findings  we  must  bear  in  mind  the 
following  points:  Small  infiltrations  do  not  show  any  definite  and 
clear-cut  signs  on  the  plate;  at  any  rate,  the  shadow  they  cast  is  not 
pathognomonic.  Cohn^  inserted  tuberculous  tissue  into  healthy  lungs 
of  cadavers,  of  which  he  took  radiograms  and  found  that  1  c.c.  of  dis- 
eased tissue  is  not  visible  on  the  plate.  Ziegler  and  Krause^  have 
investigated  the  problem  and  found  that  pieces  of  tissue  less  bulky 
than  4  c.c.  are  not  visible  on  the  skiagram,  and  that,  on  the  whole, 
small  areas  of  infiltration  are  only  visible  when  they  are  located  near 
the  surface  of  the  lung.  In  other  words,  small  infiltrations,  when 
centrally  located,  are  screened  by  normal  pulmonary  tissue,  and  may 
escape  detection.  When  the  lesion  has  caseated  it  casts  a  more  or  less 
dense  shadow.    But  then  the  case  is  no  more  incipient. 

In  many  cases  we  find  that  the  affected  apex  is  darker  than  its  mate 
on  the  opposite  side.  In  others,  the  affected  area  has  the  appearance 
of  "ground  glass."  But  even  this  does  not  invariably  imply  an  active 
lesion.  Indeed,  it  may  be  put  down  as  a  general  rule  that,  in  suspicious 
cases  showing  no  constitutional  symptoms,  the  darker  the  apex,  the 
less  likely  the  probability  of  its  being  a  sign  of  active  incipient  tubercu- 
losis. It  may  be  revealing  an  old  and  healed  lesion.  I  have  been 
impressed  with  the  following  fact:  A  considerable  proportion  of 
apparently  healthy  people  have  one  apex,  usually  the  right,  darker, 
due  to  various  causes.  In  many  it  represents  a  healed  tuberculous 
lesion,  which  is  no  longer  serious.    When  in  these  individuals  there 

1  Ztschr.  f.  Tuberkulose,  1911,  xvii,  217. 

2  Rontgenatlas  der  Lungentuberkulose,  Wiirzburg,  1910. 


296  SKIAGRAPHY  IN   THE  DIAGNOSIS  OF  PHTHISIS 

occurs  a  new  tuberculous  lesion  in  the  opposite  apex,  which  is  not 
uncommon,  it  will  give  constitutional  symptoms  calling  for  a  skia- 
graphic  examination.  The  report  from  the  radiographer  may  state 
that  the  lesion  is  located  in  the  right  side,  while  the  physical  signs 
show  conclusively  that  the  active  lesion  is  in  the  left,  or  the  reverse. 

The  divergence  of  findings  on  physical  examination  and  skiagraphy 
is  best  seen  in  far-advanced  cases  of  phthisis  in  which  a  new  lesion 
occurs  in  the  hitherto  unaffected  apex.  The  plate  does  not  show 
it  until  caseation  has  taken  place,  while  physical  exploration  reveals 
it  clearly.  I  have  had  this  incontrovertible  proof  of  the  inadequacy 
of  skiagraphy  in  incipient  lesions  repeatedly. 

For  these  reasons  we  should  not  conclude  merely  on  finding  opacities 
in  one  apex  that  we  are  dealing  with  a  case  of  incipient  phthisis.  When 
found  in  connection  with  constitutional  symptoms  and  signs  on  physical 
exploration  these  opacities  are  of  diagnostic  value.  Xor  should  we 
conclude  in  the  presence  of  constitutional  symptoms  and  local  signs 
suggestive  of  phthisis,  but  negative  skiagraphic  findings,  that  a  case 
is  not  tuberculous.  Such  a  case  requires  further  observation,  despite 
the  negative  a;-ray  findings.  I  do  not  hesitate  to  make  a  diagnosis  of 
pulmonary  tuberculosis  under  such  circumstances  when  clinical 
evidence  warrants  it. 

After  the  apex  we  carefully  examine  the  condition  of  the  roots  of  the 
lungs,  the  hilus,  with  a  view  of  ascertaining  the  presence  of  enlarged 
caseated  or  calcified  glands,  or  peribronchial  infiltrations  in  that 
region.  The  shadows  and  mottlings  observable  at  these  points  have 
been  discussed.  At  first  there  was  a  tendency  to  consider  all  abnor- 
malities as  evidences  of  enlarged  glands  and  a  diagnosis  of  tuber- 
culosis or  tuberculous  adenopathy  was  made  on  this  evidence  alone. 
But  experience  has  shown  conclusively  that  this  shadow  may  be 
caused  by  any  congestive  condition  of  the  bronchi  and  lungs,  and  it  is 
not  pathognomonic  of  phthisis.  There  is  hardly  an  adult  living  in  a 
city,  or  working  at  a  dusty  trade  who  has  no  peribronchial  thickening, 
enlarged  or  calcified  glands  at  the  hilus  of  the  lungs.  It  was  also  found 
by  Cohn,  Dunham,  Boardman,  Wolman,  Bibb  and  Gilliland,  and 
others,  that,  excepting  in  cases  with  calcified  glands,  these  shadows 
are  caused  by  blood  in  the  vessels  of  the  thorax.  Blood  absorbs  the 
x-rays  more  readily  than  infiltrated  soft  tissue  or  sputum.  Experi- 
mental injection  of  the  arteries  in  the  lungs  intensifies  the  shadow, 
and  in  human  beings  injection  of  the  vessels  with  substances  giving  a 
strong  shadow,  produce  pictures  which  are  exactly  like  those  of  normal 
lung  markings. 

This  fact  explains  many  of  the  thickenings  and  strands  noted  on 
chest  plates,  running  from  the  hilus  to  the  periphery  of  the  lungs. 
In  some  cases  they  are  due  to  bronchitis  with  congestion;  in  others, 
the  mottling  is  due  to  calcified  glands  which  are  harmless  and  of  no 
clinical  importance.  Sewall  and  Childs  report  the  case  of  a  pre- 
sumably non-tuberculous  stone-cutter  furnishing  a  skiagram  in  which, 


PLATE  III 
Fig.  1 


Radiogram  of  a  man  with  apparently  healthy  thoracic  viscera.   Dorsoventral  position. 

Fig.  2 


Same  man  as  in  Fig.  1,  but  in  the  ventrodorsal  position. 


Radiogram  of  a  woman  with  apparently  healthy  thoracic  viscera. 


Fig.  2 


Radiogram  of  the  chest  of  a  child  eight  years  old.  Though  no  symptoms  or  signs 
ot  tracheobronchial  adenopathy  could  be  found  clinically,  the  radiogram  shows  shadows 
suggestive  of  such  a  condition. 


PLATE  V 


Fig.  1 


Fig.  2, 


Lung  apex  during  ordinary  breathing. 


Apex  during  ordinary  breathing. 


Fig  3 


Fig.  4 


The  same  apex  while  patient  is  cough- 
ing, and  showing  a  narrowing  of  the 
trachea,  widening,  and  Ughtening  up  of 
the  apices,  especially  the  right.  (F. 
Hoist.) 


The  same  apex  while  patient  is  coughing, 
showing  narrowing  of  the  trachea,  and 
lightening  up  of  the  area  of  the  lung.  (F. 
Hoist.) 


The  ''Cough   Phenomenon." 


PLATE  VI 


Fig.  1 


Fig.  2 


Radiogram  of  a  case  of  abortive  tuber- 
culosis. Though  suggestive  of  an  extensive 
lesion  in  the  left  apex,  the  physical  signs, 
as  well  as  the  course  of  the  disease,  showed 
that  the  activity  of  the  process  was 
benign.  The  patient  recovered  within 
three  months. 


Radiogram  of  the  apices  in  a  case  of 
incipient  phthisis.  No  definite  changes 
are  visible,  though  physical  exploration 
revealed  a  distinct  lesion  in  the  left  apex, 
and  the  constitutional  symptoms  were 
clearly  those  of  phthisis. 


Fig.  3 


Fig.  4 


Slight  infiltration  of  the  right  apex. 
Marked  increase  in  lymphatic  tissue  in 
both  hilus  regions. 


Partial  consolidation  of  both  apices, 
large  cavity  in  left  apex.  Dilatation  of 
bronchi  of  lower  lobe  of  left  lung.  Heart 
displaced  to  the  left. 


PLATE  VJI 


Fig.  1 


Fig.  2 


Infiltration  of  right  apex.  Peribronchial 
infiltrations  and  calcified  glands  at  the 
hilus  on  both  sides. 


Very  dense  infiltration  of  right  upper 
lobe  and  large  cavity  below  the  clavicle. 
Marked  peribronchial  infiltrations.  The 
hUus  region  on  both  sides  shows  increase 
in  lymphatic  tissue. 


Fig.  3 


Fig.  4 


Large  cavity  surrounded  by  a  dense 
fibrous  wall  in  upper  part  of  right  lung. 
Enlarged  glands  in  right  hilus  region. 
Lower  half  emphysematous.  Left  lung 
shows  moderate  infiltration  beneath  the 
clavicle  and  enlarged  hilus  glands.  Drop 
heart. 


Bilateral  tuberculous  infiltration  of  both 
lungs.  Dense  hilus  region  due  to  calcifica- 
tion of  glands.  Several  small  cavities 
in  right  lung.  Adhesions  of  diaphragm. 
Trachea  markedly  pulled  over  to  the  right. 
Stomach  visible  at  left  base. 


PLATE  VIII 


Fig.  1 


Fig.  2 


Slight  infiltration  of  both  apices.  Coarse 
infiltration  of  lower  half  of  left  lung  with 
thickened  pleura.  Heart  pulled  over  to 
the  left  and  downward.  Emphysema  of 
right  lung.  Diaphragm  in  right  side 
shows  a  bulging  due  to  adhesions. 


Dense  infiltration  of  upper  third  of  left 
lung.  The  rest  presents  a  dense  homo- 
geneous shadow  caused  by  consolidation 
of  pulmonary  parenchyma  as  well  as 
thickened  pleura.  Right  lung  emphyse- 
matous and  several  enlarged  and  calcified 
glands  are  seen  at  the  hilus. 


Fig.  3 


Fig.  4 


Dense  infiltrations  of  both  apices. 
Miliary-like  infiltrations  through  both 
lungs.  Hilus  glands  greatly  enlarged  and 
apparently  calcified.  Trachea  pulled  over 
to  the  right.  Heart  small  and  dropped; 
aorta  dilated. 


Diffuse  nodular  infiltration  of  both  lungs 
with  multiple  cavitation. 


PLATE  IX 


Fig.  1 


Fig.  2 


Dense  infiltration  of  lower  half  of  right 
lung  with  thickened  pleura.  Large  cavity 
in  left  lung  occupying  apex  on  a  level 
with  first  two  interspaces.    Drop  heart. 


Diffuse  infiltration  of  both  lung  apices. 
Round  cavity,  surrounded  by  a  dense 
fibrous  capsule,  under  the  right  third  inter- 
space in  mammillary  line.  Irregularity 
of  the  diaphragm  due  to  adhesions. 


Fig.  3 


Fig.  4 


Large,  oval-shaped  cavity  in  right  apex. 
Lymphatic  tissue  at  hilus  increased. 
Cavity  in  middle  portion  of  left  lung  at 
third  interspace.  Heart  dropped;  pleuro- 
pericardial  adhesions. 


Chronic  cavitary  phthisis  in  a  child 
eight  years  of  age,  with  displacement  of 
the  heart  to  the  left. 


PLATE  X 


Fig.  1 


Fig.  2 


Syphilis  of  the  lung  simulating  in  the 
radiogram  a  tuberculous  lesion  in  the 
right  apex. 


Pulmonary  Syphilis.  Diffuse  peribron- 
chial infiltrations  of  right  lung,  mostly 
marked  at  the  lower  half.  Hilus  glands  in 
left  lung  are  distinctly  enlarged.  Peri- 
cardial adhesions  mainly  seen  in  right 
side. 


Fig.  3 


Radiogram  of  a  child  nine  years  old,  suggestive  of  enlarged  hilus  glands.  The 
symptoms  and  signs  of  this  disease  were,  however,  lacking.  Yet  on  a  level  with  the 
second  rib  an  opacity  suggestive  of  a  a  calcified  gland  can  be  seen. 


PLATE  XI 


Fig.  1 


Fig.  2 


Fig.  3 


Fig.  4 


Malignant  tumor  of  the  left  lung.  In  the  first  radiogram  the  shadow  could  not 
be  differentiated  from  a  tuberculous  lesion.  It  was  only  in  the  third  radiogram,  taken 
three  months  later,  that  the  true  nature  of  the  affection  could  be  made  out  radio- 
graphically. 


SKIAGRAPHY  297 

except  for  the  relatively  moderate  involvement  of  the  apices,  the 
mineral  deposits  occasioned  opacities  resembling  the  densest  tuber- 
culous structure.  I  have  often  had  the  same  experience  with  workers 
at  dusty  trades.  The  criterion  given  by  some  authors  for  distinguish- 
ing inactive  consolidations  and  calcified  glands  from  shadows  repre- 
senting active  lesions  by  the  fact  that  the  latter  appear  "wooly," 
does  not  hold  in  many  cases.  Any  structure  out  of  focus  appears 
diffuse — ''wooly";  even  instantaneously  taken  plates  are  not  free 
from  this  source  of  error.  "The  interpretation  of  less  dense  and  more 
diffuse  opacities  is  chiefly  guesswork"  say  Sewall  and  Childs.^  "They 
usually  represent  either  pathological  lymph  nodes  or  bloodvessels 
in  more  or  less  optical  section." 

Sources  of  Error. — The  analysis  of  these  shadows  and  mottlings 
admits  of  so  many  interpretations,  that  they  are  of  doubtful  utility 
in  most  incipient  cases.  The  "ground-glass"  appearance  of  an  apex 
is  found  in  plates  taken  from  healthy  individuals.  A  shadow,  when 
not  the  result  of  scoliosis,  shows  that  there  is  some  airless  tissue  in  that 
location.  But  we  are  not  justified  in  invariably  assuming  that  it  was 
caused  by  a  tuberculous  infiltration;  or  even  if  so,  that  the  lesion  is 
active.  Ziegler  and  Krause,  Dehn,  Arnsperger  and  others  have  found 
that  calcified  and  caseated  tissue,  and  even  fluid,  anthracotic  and 
calcified  lymph  glands  produce  the  same  radiographic  shadows.  I 
have  seen  a  large  empyema  failing  to  disclose  itself  on  an  a:-ray  plate. 

There  is  no  more  justification  for  placing  an  individual,  one  of 
whose  apices  casts  a  shadow  on  a  plate,  under  prolonged  and  costly 
treatment  than  there  is  for  the  treatment  of  one  for  mitral  insuffi- 
ciency merely  because  he  has  a  systolic  murmur  at  the  cardiac  apex. 
In  both  cases  the  clinical  symptoms  decide  whether  the  person  is  sick 
and  in  need  of  treatment. 

Because  we  are  looking,  in  incipient  cases,  for  small  areas  of  recent 
infiltration,  it  is  clear  that  we  cannot  rely  on  skiagraphy  alone  for  the 
diagnosis  of  early  phthisis.  The  skiagraphic  picture  gives  the  history 
of  the  thoracic  viscera  throughout  the  life  of  their  owner.  Any  patho- 
logical change  which  may  have  occurred  at  any  time  may  have  left 
traces  behind  which  are  likely  to  cast  shadows  or  cause  opacities  on  the 
plate.  For  this  reason,  in  incipient  or  dubious  cases  the  skiagraphic 
findings  are  to  be  taken  only  in  connection  with  constitutional  symp- 
toms and  physical  exploration  of  the  chest.  If  the  latter  are  negative, 
the  case  is  to  be  considered  non-tuberculous,  no  matter  what  the 
skiagraphic  plate  shows. 

It  is  thus  clear  that  in  the  diagnosis  of  incipient  phthisis  the  .r-rays 
are  not  of  the  value  which  some  authors  have  attributed  to  them. 
Early  tuberculous  lesions,  slightly  enlarged  bronchial  glands,  unless 
caseated  or  calcified,  as  well  as  mucous  secretions,  usually  permit 
the  rays  to  pass  through  without  casting  any  shadows  on  the  plate. 

1  Arch.  Intern.  Medicine,  1912,  x,  45. 


298  SKIAGRAPHY  IN  THE  DIAGNOSIS  OF  PHTHISIS 

Optical  sections  of  bloodvessels,  due  to  any  condition  that  may  cause 
vascular  engorgement,  may  show  opacities  on  the  plate  simulating 
the  characteristics  of  tuberculous  lesions  and  may  lead  to  error. 

.  What  is  of  most  importance  in  obscure  lesions  is  not  so  much  their 
causation,  but  their  activity.  A  healed  tuberculous  lesion  in  an  apex 
is  not  incompatable  with  excellent  health,  as  was  repeatedly  empha- 
sized. But  it  produces  a  shadow  on  the  skiagram  as  well  as,  often 
better  than,  an  active  lesion. 

Skiagraphy  may  be  of  great  assistance  in  attempts  at  localization 
of  a  lesion,  though  smaller  tuberculous  foci  may  often  be  discovered 
with  the  orthodox  clinical  methods  of  diagnosis  and  the  determination 
of  the  activity  of  an  apical  process  can  only  be  accomplished  by  careful 
observation  of  the  case,  paying  special  attention  to  the  constitutional 
symptoms,  such  as  the  temperature,  the  pulse,  cough,  expectoration, 
and  the  physical  signs.  "With  our  present  ability  to  produce  and 
interpret  .r-ray  pictures,"  say  Sewall  and  Childs,  "it  must  be  ad- 
mitted that  a  judgment  founded  on  clinical  history  combined  with 
physical  signs  may  lead  to  a  strong  suspicion  of  tuberculous  infection 
long  before  any  signs  of  actual  tissue  changes,  except  those  involving 
bronchial  glands,  appear  on  the  x-ray  negative."  Wolman,^  who  has 
worked  with  the  stereograph,  arrives  at  a  similar  conclusion.  He  says: 
"In  the  great  bulk  of  cases  the  stereograph  tells  us  no  more  than  a 
careful  clinical  examination,  yet  in  a  fair  number  of  cases,  and  those 
among  the  most  interesting  and  puzzling,  it  gives  additional  informa- 
tion. But  we  must  add  the  caution  that  a  careful  history  is  indispen- 
sable, since  not  even  the  stereograph  can  tell  an  active  from  a  healed 
lesion." 

Skiagraphy  in  Advanced  Stages  of  Phthisis. — In  my  experience  skiag- 
raphy has  been  of  greater  utility  in  the  diagnosis  of  advanced  disease 
than  in  early  or  dubious  cases.  Very  often  we  find  that  the  x-ray 
plate  reveals  more  extensive  involvement  than  the  findings  on  physical 
exploration  of  the  chest,  and  the  prognostic  significance  is  thus  in- 
valuable. In  cases  in  which  the  question  of  artificial  pneumothorax 
is  considered,  skiagraphy  offers  invaluable  assistance.  Very  often 
pleural  effusions,  especially  the  localized  or  interlobar  varieties,  are 
discovered,  though  they  have  escaped  detection  by  routine  methods. 
The  same  is  true  of  localized  pneumothorax. 

The  radiographic  picture  of  advanced  phthisis  is  variegated,  de- 
pending on  the  changes  in  the  lungs  and  pleura.  The  intensity  of  the 
shadows  cast  by  the  lesions  depends  on  their  nature  and  density. 
Caseated  and  calcified  areas  cast  dense  shadows,  while  proliferation 
of  tissue,  especially  when  it  is  also  congested,  or  fibrosis  is  also 
clearly  detected.  Old,  indurated  areas  are  usually  more  or  less  sharply 
demarcated  from  the  surrounding  tissues,  while  with  new,  active 
infiltrations  the  shadow  merges  by  degrees  with  the  surrounding  air- 

1  Johns  Hopkins  Hosp.  Bull.,  1911,  xxii,  23G. 


PNEUMOTHORAX  AND  PULMONARY  EMPHYSEMA         299 

containing  lung  tissue.  Thick  pleura  is  discovered  by  a  dense,  uniform 
shadow,  and  all  connective-tissue  formations  reveal  themselves  in  the 
same  manner.  More  often  than  by  physical  exploration,  cavities 
disclose  themselves  by  showing  limited  areas  lacking  in  lung  markings 
and  surrounded  by  thick  shadows  (Plate  VII).  They  may  often  be 
seen  moving  during  inspiration  and  expiration  when  examined  with 
the  fluoroscopic  screen.  But  when  a  cavity  is  filled  with  secretions, 
it  is  again  airless,  and  casts  the  shadow  of  the  surrounding  tissues, 
and  a  very  much  thickened  pleura  may  cover  up  a  cavity.  A  cavity 
may  also  be  screened  by  the  surrounding  healthy  lung  tissue.  Thus, 
we  often  fail  to  find  it  with  the  cc-rays,  while  physical  exploration 
reveals  it  easily.  "One  must  use  great  caution  in  diagnosing  cavities 
as  the  result  of  the  plate  alone,"  says  Ray  W.  Matson,  "  Adhesive  bands 
when  circularly  arranged,  so  closely  resemble  cavities  that  even  an 
expert  will  make  mistakes  if  his  work  is  not  controlled  by  physical 
examination  and  clinical  history." 

Kuthy  and  Wolff-Eisner  point  out  a  fact  which  in  my  experience 
occurs  very  often:  When  the  signs  found  by  percussion  show  a  more 
extensive  lesion  than  the  radiogram  shows,  then  it  is  the  thickened 
pleura  which  produces  the  dulness.  Conversely,  when  the  signs 
obtained  by  percussion  are  of  smaller  extent  than  the  radiogram 
reveals,  there  is  a  central  parenchymatous  lesion  of  very  serious 
import. 

The  condition  of  the  pleura  may  be  studied  on  the  plate.  Fibrinous 
pleurisy  is  not  shown  at  all.  But  effusions  reveal  themselves  clearly 
as  an  intense  shadow  on  the  plate.  Its  upper  level  is  clearly  demar- 
cated from  the  lung  above,  and  in  the  fluoroscope  it  may  be  seen  moving 
somewhat  with  the  respiratory  movements.  When  the  quantity  of 
fluid  is  small,  it  may  escape  detection  when  sinking  down  in  the 
diaphragm.  In  hydropneumothorax  it  is  important  that  the  exposure 
should  be  made  with  the  patient  in  the  erect  posture,  because  when 
lying  down  small  quantities  of  fluid  spread  in  a  thin  layer  and  may 
escape  detection.  In  hydropneumothorax  the  upper  layer  of  the  fluid 
forms  a  sharp  line,  while  in  pleurisy  with  effusion  the  upper  level  is 
usually  not  so  sharp,  but  gradually  merges  with  the  lung  tissue  above 
it.  The  fact  that  in  the  latter  case  the  level  does  not  shift  with  motion 
of  the  patient's  chest,  shows  that  it  is  not  a  hydropneumothorax; 
in  the  latter  case  it  does  shift  (see  Plate  XVI,  Fig.  2). 

The  displacements  of  the  mediastinum  caused  by  pleural  effusion 
are  best  made  out  with  the  cc-rays;  but  it  is  impossible  to  distinguish 
between  fluid  and  the  liver  in  right-sided  effusions.  Dislocation  of  the 
trachea  and  larynx  may  often  be  discovered  on  the  plate  (Plate  VIII) . 

Skiagraphy  in  Pneumothorax  and  Pulmonary  Emphysema. — 
Skiagraphy  finds  its  greatest  field  of  usefulness  in  our  attempts  at 
discerning  the  changes  in  the  thoracic  organs  during  the  course  of 
phthisis  in  revealing  pneumothorax,  especially  of  the  localized  variety 
which  formerly  escaped  recognition.    Complete  pneumothorax  appears 


300  SKIAGRAPHY  IN  THE  DIAGNOSIS  OF  PHTHISIS 

clearly  on  the  fluorescent  screen  or  the  skiagraphic  plate  as  a 
bright  area,  lacking  in  lung  markings;  in  contrast  with  the  opposite 
expanded  lung  it  may  be  said  to  be  brilliant.  The  collapsed  lung 
is  seen  lying  near  the  mediastinum  or  against  the  spinal  column  as 
a  dark  band.  Deep  breathing  has  no  influence  in  changing  the  appear- 
ance of  the  affected  area.  The  dome  of  the  diaphragm  is  lower  than, 
and  the  mediastinum  is  displaced  to,  the  unaffected  side.  The  forms 
of  pneumothorax  which  are  localized,  "silent,"  and  may  even  give 
no  symptoms,  or  only  indefinite  symptoms  and  signs,  are  easily  dis- 
cerned. In  those  anomalous  cases  in  which  pleural  adhesions  prevent 
the  induction  of  an  artificial  pneumothorax,  still  negative  pressure  is 
obtained  and  gas  is  inflated,  we  could  not  be  enlightened  that  our 
labors  are  vain  efforts  without  skiagraphy  showing  that  no  pneumo- 
thorax has  been  created  despite  the  fact  that  several  inflations  of  gas 
have  been  made.  A  pneumothorax  occupying  a  part  of  the  chest,  as 
is  shown  in  Plate  XIV,  Fig.  3,  could  not  be  discovered  without  the 
aid  of  skiagraph^^ 

Emphysema,  too,  is  easily  recognized  with  the  a-rays.  The  lungs  are 
brighter  than  normal  because  of  the  dilated  alveoli  and  greater  air 
content.  But  the  translucency  is  not  as  intense  as  in  pneumothorax, 
and  lung  markings  are  still  made  out.  The  ribs  are  widely  separated, 
run  horizontally,  and  their  motion  during  respiration  is  impaired. 
During  the  course  of  phthisis  the  unaffected  lung  is  often  found 
emphysematous  owing  to  vicarious  function;  often  we  find  only  parts 
of  one  lung,  or  one  lobe  emphysematous  for  this  reason.  Skiagraphy 
clears  these  matters  up. 


CHAPTER  XVIII. 
THE  CLINICAL  FORMS  OF  PHTHISIS. 

POLYMORPHISM    OF    THE    CLINICAL   PHENOMENA    OF 
PHTHISIS. 

Laennec  showed  clearly  the  unity  of  the  elemental  pathological 
changes  found  in  phthisis  and  Koch,  discovering  the  tubercle  bacillus, 
proved  it  etiologically.  But  all  attempts  to  impose  this  unity  on  the 
clinical  manifestations  of  tuberculous  diseases  of  the  lungs  have  failed 
dismally.  In  pathology,  particularly  in  clinical  medicine,  unity  of 
causation  does  not  always  indicate  unity  of  effect.  Especially  is  this 
true  of  a  polymorphous  disease,  as  pulmonary  phthisis. 

A  study  of  the  morbid  anatomy  of  phthisis  shows  great  polymor- 
phism— there  are  hardly  two  cases  showing  the  same  changes  in 
structure.  There  are  cases  in  which  the  lesions  are  purely  proliferative, 
characterized  by  the  formation  of  tubercles,  as  is  the  case  with  acute 
miliary  tuberculosis;  in  others  they  are  mainly  exudative,  as  in  chronic 
phthisis.  But  in  the  latter  the  difference  in  the  intensity  of  the  pro- 
ductive inflammation,  which  tends  to  limit  the  morbid  process,  and 
the  process  of  necrosis,  which  tends  to  extend  it,  produce  a  diversity 
of  lesions  which  have  important  bearings  on  the  clinical  picture, 
course,  and  prognosis  of  the  disease. 

This  is  to  be  expected  when  we  consider  that  the  disease  produced 
by  the  tubercle  bacilH  depends  on  the  interaction  of  two  forces  of 
inconstant  intensity,  viz.: 

1.  On  the  intensity  of  the  infection.  This  depends  on  the  number 
of  bacilli  which  have  entered  the  body;  their  virulence  which  we 
know  is  variable,  depending  on  the  type,  and  the  condition  under 
which  they  existed  before  entering  the  body,  etc.,  and  on  the  portals 
of  entry.  It  is  doubtful  whether  infection  by  inhalation  will  produce 
the  same  clinical  picture  as  infection  by  ingestion  or  by  inoculation ; 
whether  hematogenic  tuberculosis  will  produce  the  same  symptoms 
as  aerogenic  or  lymphogenic  infection. 

2.  On  the  resistance  of  the  host,  which  is  also  an  inconstant  value, 
depending  as  it  does  on  certain  and  uncertain,  constant  and  tempo- 
rary, conditions  which  cannot  always  be  defined  clearly.  Thus,  the 
effects  of  the  infection  depend  on  the  age  at  which  it  has  taken  place. 
During  the  first  six  or  twelve  months  of  life  massive  infection  pro- 
duces a  different  disease  than  during  the  succeeding  years  of  child- 
hood. Acute  miliary  tuberculosis  is  common  at  the  former  age,  while 
tuberculosis  of  the  glands,  bones  and  joints  is  mostly  seen  at  the  later 
ages.     Primary  infection  of  an  adult  is  usually  followed  by  clinical 


302  THE  CLINICAL  FORMS  OF  PHTHISIS 

phenomena  which  differ  markedly  from  those  seen  in  individuals  who 
were  presumably  infected  during  childhood  and  the  bacilli  remained 
dormant  for  many  years.  We  have  already  discussed  the  effects  of 
preexisting  diseases  on  the  type  and  course  of  phthisis. 

"To  speak  of  pulmonary  tuberculosis  as  an  entity,"  says  von  Hanse- 
mann/  "and  to  describe  it  as  one  disease  caused  by  the  tubercle 
bacillus  is  hardly  conceivable.  One  has  to  compare  pure  miliary  tuber- 
culosis of  the  lungs  with  chronic  indurative  phthisis,  and  the  latter 
with  acute  florid  phthisis  or  caseous  hepatization  of  the  lungs,  to  find 
clearly  that  they  are  different  pathological  pictures  which  defy  all 
comparisons.  For  these  reasons  it  is  altogether  impossible  to  speak 
simply  of  pulmonary  tuberculosis  and  thereby  retain  a  clear  survey 
of  the  different  forms  of  the  disease.  In  reality  we  are  compelled  to 
draw  a  sharp  line  of  demarcation  between  these  different  forms  of 
the  disease,  even  when  we  are  inclined  to  consider  the  tubercle,  bacilli 
as  the  underlying  etiological  cause  of  all  the  forms  of  the  disease." 

The  Stages  of  Phthisis. — Early  writers  on  phthisis,  who  were 
innocent  of  modern  methods  of  diagnosis,  felt  constrained  to  differ- 
entiate various  forms  of  the  disease  as  they  saw  it  clinically.  They 
divided  it  into  three  stages:  Phthisis  incipiens,  phthisis  confirmata, 
and  phthisis  desperata.  Bayle,  in  the  first  decenium  of  the  nineteenth 
century,  added  a  fourth  stage.  Phthisis  occulta,  or  gervie  de  la  phtisie, 
which  corresponds  to  the  modern  pretuberculous  stage,  when  the 
tubercles  in  the  lung  are  too  few  to  produce  symptoms.  Laennec, 
who  was  an  excellent  and  pioneer  pathologist  and  clinician,  having 
invented  auscultation,  divided  phthisis  into  three  stages,  basing  his 
classification  on  anatomical  grounds.  He  divided  phthisis  into: 
First  stage,  the  accumulation  of  the  tubercles,  which  betray  themselves 
by  bronchophony  and  dulness  over  the  affected  area;  second  stage, 
softening  of  the  lesion,  producing  bronchial  breathing,  coarse  rales 
and  pectoriloquy;  and  third  stage,  the  elimination  of  the  softened 
area,  leaving  pulmonary  excavations  which  may  be  found  by  careful 
physical  exploration. 

This  division  of  phthisis  into  three  or  four  stages  has  remained 
to  date  not  only  among  the  laity,  who  fear  the  second  and  third 
stages,  but  also  among  physicians,  who  are  always  aiming  at  discover- 
ing the  disease  in  the  pretuberculous  stage,  or  at  least  in  the  first, 
or  incipient  stage.  Some  even  maintain  that  the  disease  is  curable 
only  at  this  stage.    That  this  is  not  always  true  will  be  shown  later  on. 

OFFICIAL   CLASSIFICATIONS   OF   THE   STAGES  OF  PHTHISIS. 

With  the  advance  of  knowledge  of  the  clinical  manifestations,  and 
the  methods  of  recognition  of  the  disease,  the  stages  into  which  phthisis 
is  divided  remained  practically  the  same.    They  have  only  been  more 

1  Berl.  kliu.  Wclmschr.,  1911,  xlvii,  1. 


OFFICIAL  CLASSIFICATIONS  OF  STAGES  OF  PHTHISIS    303 

exactly  defined.  In  Germany  the  classifications  of  Turban  and 
Gerhardt  have  gained  wide  acceptance,  while  in  this  country,  the 
American  Sanatorium  Association  and  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis  have  adapted  the 
following  classification: 

Incipient. — Slight  initial  lesion  in  the  form  of  infiltration  limited 
to  the  apex  of  one  or  both  lungs  or  a  small  part  of  one  lobe.  No 
tuberculous  complications.  Slight  or  no  constitutional  symptoms 
(particularly  including  gastric  or  intestinal  disturbance  or  rapid  loss 
of  weight). 

Expectoration  usually  small  in  amount  or  absent. 

Tubercle  bacilli  may  be  present  or  absent. 

Moderately  Advanced. — No  marked  impairment  of  function,  either 
local  or  constitutional.  Localized  consolidation  moderate  in  extent 
with  little  or  no  evidence  of  destruction  of  tissue  or  disseminated 
fibroid  deposits.    No  serious  compHcations. 

Far  Advanced. — Marked  impairment  of  function,  local  and  con- 
stitutional. Localized  consolidation  intense,  or  disseminated  areas  of 
softening,  or  serious  complications. 

Shortcomings  of  the  Official  Classifications. — If  the  object  of  this 
classification  is  to  define  the  prognosis  of  phthisis,  it  fails  utterly.  A 
patient  with  a  "slight  initial  lesion  in  the  form  of  an  infiltration  of  the 
apex"  has  not  always  a  greater  expectation  of  life  than  one  having 
"marked  local  impairment  of  function,  and  extensive  destruction  of 
tissue."  In  fact,  in  acute  miliary  tuberculosis  of  the  lungs,  the  lesion 
is  so  slight  that  it  can  often  not  Ibe  localized  during  life.  On  the  other 
hand,  many  cases  of  phthisis  with  extensive  excavations  have  a  better 
outlook,  at  least  as  regards  duration  of  life,  and  even  as  regards  regain- 
ing efficiency,  than  some  with  limited  lesions  at  one  apex,  without 
expectoration  of  tubercle  bacilli  but  with  evidences  of  toxic  activity. 
Moreover,  it  is  clinically  wrong  to  put  into  one  class  the  incipient  cases 
showing  no  fever,  no  tachycardia  "at  any  time  during  the  twenty- 
four  hours,"  no  gastric  or  intestinal  disturbances,  no  rapid  loss  of 
weight,  etc.,  which  are  evidently  cases  of  abortive  tuberculosis,  if  at 
all  actively  tuberculous,  with  those  having  lesions  limited  to  one  or 
both  sides  and  who  do  show  constitutional  symptoms  of  toxemia. 
The  former  will  recover  within  a  few  months  under  any  rational  form 
of  treatment,  or  spontaneously,  while  the  latter  may  not,  even  with  the 
most  rigid  institutional,  climatic,  dietetic,  or  specific  treatment. 

Any  physician  having  opportunities  to  observe  many  tuberculous 
cases  is  struck  with  the  fact  that  the  prognosis,  immediate  and  ultimate, 
does  not  entirely  depend  on  the  changes  in  the  breath  sounds,  the 
presence  or  absence  of  rales  and  signs  of  excavations  in  the  lungs. 
The  constitutional  symptoms  such  as  fever,  pulse  rate,  presence  or 
absence  of  dyspnea,  gastric  disturbances,  and  above  all  the  resistance 
of  the  patient,  play  a  greater  role  in  the  ultimate  outcome  of  a  case 
than  the  anatomical  changes. 


304  THE  CLINICAL  FORMS  OF  PHTHISIS 

In  order  that  a  case  may  be  considered  "incipient,"  according  to 
this  classification,  and  nearly  all  others  which  have  been  devised,  the 
constitutional  disturbances  must  be  slight  or  absent.  Thus,  in  the 
definition  of  terms  it  is  stated  that  "the  impairment  of  health  may  be 
so  slight  that  the  patient  does  not  look  or  feel  sick  in  the  ordinary 
sense  of  the  word."  The  pulse  should  not  exceed  90  per  minute  and 
the  temperature  99.5°  F.,  and  the  sputum  may  be  negative.  The 
physical  signs  consist  in  "slight  prominence  of  the  clavicle,  lessened 
movement  of  the  chest,  narrowing  of  the  apical  resonance  with  les- 
sened movement  of  the  base  of  the  lung,  slight,  or  no  change  in  reson- 
ance, distinct  or  loud  and  harsh  breathing  with  or  without  some 
changes  in  the  rhythm  (i.  e.,  prolonged  expiration),  vocal  resonance 
possibly  slightly  increased;  or  fine  or  moderately  coarse  rales  present 
or  absent.  If  sputum  contains  tubercle  bacilli,  any  one  of  these." 
Considering  that  the  apex  is  defined  as  "that  portion  of  the  lung 
situated  above  the  clavicle  and  the  third  vertebral  spine,"  it  is  clear 
that  the  lesion  must  be  quite  limited,  often  of  the  type  considered 
"dubious"  by  some  clinicians. 

All  these  symptoms,  or  absence  of  constitutional  symptoms,  and 
signs  in  the  chest  may  be  found  in  a  large  proportion  of  persons  in  all 
walks  of  life,  working  hard  at  their  occupations,  who,  if  followed  for 
many  years,  are  not  found  to  develop  active  phthisis.  People  with 
collapse  induration  often  show  more  distinct  physical  signs  at  one 
apex,  yet  they  are  not  phthisical. 

On  the  other  hand,  a  really  phthisical  person  showing  so  few  signs 
on  physical  exploration,  but  in  whom  the  disease  is  pursuing  an  acute 
or  subacute  course,  may  be  carried  off  much  quicker  than  many  with 
extensive  involvement,  but  manifesting  a  tendency  to  chronicity  of 
the  process. 

It  cannot  be  denied  that  these  three  or  four  stages  of  tuberculosis 
are  altogether  arbitrary.  We  cannot  often  separate  them  by  sharp 
lines  of  demarcation  and  say  "this  is  a  first  stage  case,"  or  "this  case 
is  passing  from  the  second  into  the  third  stage,"  etc.  There  are 
always  transitional  forms.  There  are  also  numerous  cases  showing 
healed  lesions  which  at  the  time  of  activity  were  in  the  third  stage, 
but- give  no  more  trouble — while  an  initial  lesion  in  the  other  lung  is 
responsible  for  the  disease  for  which  the  patient  consults  the  physician. 
Such  cases,  incipient  in  the  true  sense  of  the  word,  must  be  considered 
far  advanced  according  to  this  classification.  It  is  also  a  fact  that,  for 
phthisis  to  end  fatally,  it  is  not  necessary  that  the  lesion  in  the  lung 
should  soften  and  produce  a  cavity;  caseation  alone,  when  extending 
rapidly,  may  kill;  the  patient  has  thus  not  reached  the  third  stage, 
yet  he  dies.  On  the  other  hand,  we  have  numerous  patients,  who, 
despite  the  fact  that  they  have  more  or  less  extensive  excavations  in 
the  lungs,  are  in  fact  in  the  third  stage  of  phthisis,  yet  they  feel  well, 
and  are  even  efficient  at  their  occupations,  and  when  they  finally  die 
the  cause  may  be  another  disease. 


CLASSIFICATION  IN  THE  PRESENT  WORK  305 

For  these  reasons  some  clinicians  have  been  constrained  to  distinguish 
the  various  forms  of  phthisis  met  with  in  practice  into  different  chn- 
ical  entities.  Thus,  even  the  classification  mentioned  above  considers 
acute  miliary  tuberculosis  as  a  distinct  disease.  Other  authors,  like 
Alfred  Loomis,  Williams,  Andrew  Clark,  Douglas  Powell,  etc.,  have 
described  fibroid  phthisis — ^which  in  the  above  classification  would 
always  be  included  among  the  advanced  cases — as  a  distinct  disease. 

Many  writers  on  this  subject  have  gone  much  further  and  distin- 
guished not  only  acute  and  chronic  forms  of  the  disease  but  have  also 
described  congenital,  or  hereditary  and  acquired,  forms  of  the  dis- 
ease; phthisis  in  arthritic,  gouty,  diabetic,  nephritic,  alcoholic,  or 
syphilitic  subjects;  also  according  to  some  prominent  symptoms,  such 
as  hemorrhagic,  bronchitic,  bronchiectatic,  pleuritic  phthisis.  In 
accordance  with  certain  etiological  factors,  there  has  been  described 
phthisis  in  workers  at  dusty  occupations,  such  as  miner's  phthisis,  etc. 
Finally  tuberculosis  of  the  lungs  in  children  has  always  been  consid- 
ered as  presenting  a  different  clinical  picture  from  that  in  the  adult; 
while  in  aged  persons  the  symptomatology  of  phthisis  differs  from 
that  in  younger  individuals. 

Classification  in  the  Present  Work. — The  classification  of  the 
diversity  of  clinical  types  of  tuberculosis  of  the  lungs,  to  be  of  practical 
value,  if  it  is  to  be  attempted  at  all,  must  have  a  prognostic  value. 
For  this  reason  the  acute  forms  of  the  disease  are  to  be  separated  into 
•a  class  by  themselves,  as  has,  in  fact,  been  done  by  all  writers  on  the 
subject.  In  chronic  phthisis  the  ultimate  outcome  of  the  disease 
depends  mainly  on  the  relative  intensity  of  the  two  processes  in  the 
lungs,  the  destructive  and  the  reparative,  the  former  manifesting 
itself  by  caseation  and  softening,  and  the  latter  by  the  formation  of 
fibrous  tissue  which  limits  the  destructive  process  and  even  heals 
the  lesion  by  cicatrization.  Both  processes,  fibrosis  and  necrosis,  are 
caused  by  the  tubercle  bacilli.  And  inasmuch  as  there  are  many  cases 
in  which  the  fibrosis  dominates  the  anatomical  changes  in  the  lungs, 
and  the  symptoms  thus  produced  differ  from  those  in  which  the 
caseating  process  predominates,  it  is  clear  that  there  is  justification 
for  separation  of  fibroid  phthisis  into  a  distinct  class  of  the  disease. 
This  justification  is  fortified  by  the  fact  that  the  prognosis  of  fibroid 
phthisis  is  distinctly  more  favorable  than  that  of  chronic  caseous 
phthisis,  and  the  treatment  indicated  is  different  than  that  in  other 
forms. 

In  common  chronic  phthisis  we  find  that  among  the  cases  which 
have  been  described  as  "incipient,"  there  are  many  which  show  a 
marked  tendency  to  cicatrization  of  the  lesion,  spontaneously  or  after 
some  treatment  for  a  few  months.  In  the  vast  majority  of  cases 
this  form  of  phthisis  is  not  at  all  recognized  and  only  at  the  autopsy 
some  scars  or  calcified  foci  are  found  in  the  lung  or  pleura  showing 
that  the  person  had  survived  a  tuberculous  lesion.  To  treat  these 
cases  in  the  same  manner  as  we  treat  common  chronic  phthisis  is 
20 


306  THE  CLINICAL  FORMS  OF  PHTHISIS 

wrong.  We  should,  when  diagnosticating  a  case  of  this  kind,  tell  the 
patient  that  his  malady  is  relatively  trifling,  and  that  he  will  recover 
within  a  few  months,  if  he  observes  ordinary  hygienic  and  dietetic 
rules.  We  can  often  also  spare  him  the  trouble  and  the  economic 
danger  of  giving  up  his  business  which  is  usually  necessar}'  in  cases 
of  chronic  phthisis.  We  have  therefore  described  abortive  tubercu- 
losis as  a  distinct  clinical  type  of  the  disease. 

Most  of  the  victims  of  tuberculosis  who  succumb  to  the  disease,  or 
who  suffer  from  it  for  long  periods  of  time  even  if  they  recover,  are 
affected  with  chronic  phthisis.  This  disease  is  characterized  by  an 
undulating  course,  marked  by  periods  of  quiescence  of  longer  or 
shorter  duration,  and  interrupted  by  periods  of  acute  or  subacute 
exacerbations.  In  fact  it  may  be  stated  that  acute  progressive  phthisis, 
or  galloping  consumption,  consists  clinically  in  an  acute  exacerbation 
of  the  disease  which  is  not  followed  by  a  period  of  quiescence.  In  the 
chronic  type  of  the  disease,  proper  and  timely  treatment  may  save 
the  patient,  while  negligence  in  this  regard  is  apt  to  prove  disastrous. 
For  this  reason  it  is  imperative  that  it  should  be  recognized  as  early 
as  possible.  We  have  therefore  divided  the  subject  into  two  parts: 
incipient  phthisis  and  advanced  phthisis.  The  former,  if  recognized 
in  time,  and  appropriate  treatment  applied,  may  often  be  aborted; 
or  acute  exacerbations  leading  to  irreparable  damage  of  the  lungs  and 
other  organs  and  functions  may  be  prevented.  The  latter,  when 
properly  cared  for,  may  be  kept  in  check  so  that  acute  exacerbations 
occur  less  frequenth',  or  not  at  all,  and  cicatrization  of  the  lesion  goes 
on  unhindered. 

We  also  know  that  tuberculosis  in  children  is  anatomically,  and  also 
clinically,  not  of  the  same  character  as  that  in  adults.  In  the  former 
the  glands,  bones  and  joints,  while  in  the  latter  the  lungs,  are  mainly 
the  organs  which  bear  the  brunt  of  the  infection.  Indeed,  consider- 
able harm  is  done  to  children  by  treating  them  for  clironic  pulmonary 
tuberculosis  which,  before  the  eighth  year  of  life,  they  practically 
tiever  have.  For  this  reason,  the  disease  as  it  occurs  in  infants  and 
children  merits  separate  description.  Because  in  infancy  the  infec- 
tion is  usually  followed  by  acute  manifestations,  while  in  children 
between  two  and  ten  years  of  age  chronic  disease  of  the  glands  occurs, 
we  shall  speak  of  tuberculosis  in  infants,  and  tuberculosis  in  children. 

Finally,  it  is  now  known  that  phthisis  occurs  in  the  aged  just  as 
frequently  as  in  younger  individuals,  but  that  it  is  not  recognized 
very  often  because  of  the  peculiar  symptomatology  it  presents.  The 
aged  consumptives,  believing  that  they  only  suffer  from  chronic 
bronchitis,  asthma  or  pulmonary  emphysema,  are  sources  of  infection 
to  an  extent  not  as  fully  appreciated  as  they  deserve.  We  have  there- 
fore devoted  a  special  chapter  dealing  with  tuberculosis  in  the  aged, 
pointing  out  its  clinical  characterization. 

These  forms  of  phthisis  do  not  exliaust  the  subject  of  the  clinical 
polymorphism  of  this  disease.     There  are  many  other  types  which 


CLASSIFICATION  IN  THE  PRESENT  WORK  307 

may  be  appreciated  when  carefully  studying  the  cases,  while  quite 
often  these  types  overlap  one  another  to  an  extent  as  to  render  it 
difficult  to  decide  to  which  class  a  case  belongs.  But  for  practical 
purposes  these  clinical  classes  are  sufficient.  They  assist  in  appreciat- 
ing the  course  of  the  disease  when  it  occurs,  and  give  us  hints  for  prog- 
nosis and  treatment  which  are  invaluable  and  which  cannot  be  had 
when  pulmonary  tuberculosis  is  considered  as  a  single  clinical  entity. 
We  shall  therefore  describe  phthisis  under  the  following  headings: 

1.  Chronic  phthisis,  incipient  stage. 

2.  Chronic  phthisis,  advanced  stage. 

3.  Acute  phthisis. 

4.  Fibroid  phthisis. 

5.  Abortive  pulmonary  tuberculosis. 

6.  Pulmonary  tuberculosis  in  children. 

7.  Phthisis  in  the  aged. 


CHAPTER  XIX. 
CHRONIC  PHTHISIS.    INCIPIENT  STAGE. 

INCIPIENT   PHTHISIS. 

Onset. — A  lay  writer/  describing  his  own,  subsequently  fatal  case 
of  phthisis,  in  speaking  of  his  "initiation  into  T.  B.,"  says:  "The 
entrances  are  innumerable,  however  sole  the  exit.  Indeed,  the  initia- 
tion varies  so  widely  that  one  would  not  be  far  wrong  in  saying  that 
it  is  never  twice  the  same.  Yet  many  initiations  have  certain  features 
in  common;  and  in  a  general  way  it  may  be  said  that  all  belong  to 
one  of  two  great  classes — the  sudden  and  the  protracted."  No 
physician,  however  extensive  his  experience  with  phthisis,  could  do 
more  justice  to  the  subject,  or  make  a  better  generalization  of  the 
various  ways  in  which  phthisis  is  likely  to  begin. 

A  sudden  or  abrupt  onset  of  phthisis  is  infrequent,  btit  it  does  occur. 
We  meet  with  patients  who  have  been  in  the  best  of  health;  have  no 
ascertainable  hereditary  taint;  have  not  come  into  immediate  or 
intimate  contact  with  a  consumptive  as  far  as  they  can  remember; 
have  not  overworked,  not  suffered  from  exposure,  but  they  suddenly 
begin  to  cough,  lose  weight,  have  fever,  feel  tired  at  the  least  exertion, 
and  a  careful  physical  examination  reveals  a  small,  but  progressive 
lesion  at  one  apex.  We  meet  with  others  who,  without  any  premonitory 
symptoms,  without  any  exciting  cause,  suddenly  perceive  a  warm 
sensation  in  the  throat,  cough  and  bring  up  a  mouthful  of  blood.  The 
hemoptysis  may  be  scanty  or  copious,  but  the  signs  elicited  while 
examining  the  chest  leave  no  doubt  that  it  is  derived  from  a  pulmonary 
lesion,  and  the  subsequent  course  of  the  disease  proves  conclusively 
that  we  are  dealing  with  phthisis.  Still  others,  after  an  indiscreet 
exposure  to  the  vicissitudes  of  the  weather,  or  after  a  cold  bath  to 
which  they  are  not  accustomed,  begin  to  cough  and  are  treated  for  a 
"cold,"  "grippe,"  etc.,  for  some  time.  But  the  symptoms  fail  to  amel- 
iorate in  spite  of  careful  treatment,  M^hen  one  day  a  careful  examina- 
tion of  the  chest  shows  a  distinct  lesion,  or  a  bacteriological  examina- 
tion of  the  sputum  reveals  the  presence  of  tubercle  bacilli.  In  some, 
exposure  may  bring  on  an  attack  of  pleurisy,  dry  or  with  effusion,  the 
subsequent  course  of  which  is  distinctly  that  of  phthisis. 

But  in  a  lar'ge  proportion  of  cases  the  disease  develops  slowly,  insid- 
iously— the  initiation  is  protracted  as  our  lay  friend  said.  For  months 
or  years  the  patient  has  not  been  well.  He  was  "subject  to  colds," 
and  every  autumn  or  winter  he  passed  through  one  or  more  attacks 

1  The  Atlantic  Monthly,  Junu,  1914,  cxiii,  747. 


INCIPIENT  PHTHISIS  309 

of  "grippe,"  bronchitis,  etc.,  with  cough,  expectoration,  fever,  malaise, 
etc.,  but  he  soon  recuperated  and  worked  more  or  less  efficiently  at 
his  vocation.  Finally  one  attack  sticks  and  he  does  not  improve,  not- 
withstanding the  remedies  which  were  formerly  effective. 

In  young  men  the  symptoms  which  we  are  apt  to  label  as  "neuras- 
thenia," may  have  been  present  for  a  year,  two,  or  more.  What  was 
most  annoying  and  could  not  be  relieved  by  the  usual  treatment 
instituted  was  the  languor,  the  tired  feeling  which  overwhelmed  the 
patient  before  his  day's  work  was  at  an  end.  He  may  be  complain- 
ing of  cardiac  palpitation,  indefinite  pains  in  the  chest,  some  cough 
in  the  morning,  etc.  But  on  the  whole  he  considered  himself  "run 
down,"  and  sadly  in  need  of  a  rest. 

In  young  women  the  subjective  and  objective  symptoms  of  chlorosis 
may  have  been  present  for  months  or  years.  An  examination  of  the 
blood  has,  indeed,  shown  a  low  percentage  of  hemoglobin,  and  large 
doses  of  some  iron  preparation  have  been  used.  Some  have  had 
irregularities  in  the  menstrual  function,  perhaps  amenorrhea  for 
several  months,  and  even  this  was  attributed  to  the  anemia.  But 
then  they  begin  to  cough;  and  the  cough  persists  in  spite  of  treat- 
ment, when  an  examination  of  the  chest  or  of  the  sputum  tells  the  story. 

Others  have  been  "run  down"  from  overwork,  physical  or  mental, 
for  a  long  time  till  it  is  discovered  that  the  cause  of  their  debility  is 
located  in  the  lungs.  In  many  patients  the  symptoms  of  dyspepsia 
are  so  pronounced  as  to  preclude  a  careful  examination  of  the  chest 
and  they  are  treated  for  a  long  time  for  "stomach  trouble." 

This  does  not  exhaust  the  variety  of  symptoms  which  may  slowly 
but  surely  usher  in  phthisis.  But  numerous  as  they  are,  they  have 
certain  features  in  common  which  characterize  phthisis  in  the  vast 
majority  of  cases,  so  that  if  this  disease  is  only  borne  in  mind — and  it 
should,  considering  its  great  prevalence — more  really  incipient  cases 
would  be  recognized  than  at  present.  These  clinical  phenomena  will 
now  be  discussed. 

Symptoms. — Practically  all  patients  with  incipient  phthisis  cough 
at  a  very  early  stage  of  the  disease,  and  the  cases  without  cough, 
which  have  been  mentioned  by  various  authors,  are  rare  clinical 
phenomena,  at  least  they  are  exceedingly  rare  among  persons  under 
fifty  years  of  age,  and  may  be  disregarded.  It  was  already  stated  that 
patients  who  claim  that  they  do  not  cough  are  usually  individuals 
who  overlook  a  mild  cough,  but  those  around  them  are  apt  to  notice 
that  they  do,  and  in  doubtful  cases  it  is  advisable  to  inquire  among 
those  who  live  with  the  patient. 

A  person  who  never  coughed  before,  but  after  a  "cold"  coughs  for 
more  than  two  weeks  should  excite  interest  and  careful  study.  If  he 
vomits  after  fits  of  coughing,  tuberculosis  is  to  be  strongly  suspected. 
Paroxysmal  coughing  spells  are  also  apt  to  take  place  during  the  night 
and  keep  the  patient  awake.  Very  little  expectoration  is  apt  to  be 
brought  up  at  this  period — at  most  some  viscid  mucus  which  contains 


310  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

no  tubercle  bacilli,  nor  elastic  tissue,  though  animal  inoculation  may  be 
effective  in  disclosing  the  tuberculous  nature  of  the  trouble. 

Languor  is  a  constant  symptom  at  a  very  early  stage — the  patient 
feels  tired  in  the  morning  at  rising,  but  recuperates  after  working  for 
a  few  hours.  But  in  the  later  part  of  the  afternoon  he  feels  fatigued, 
often  drowsy,  inclined  to  sleep.  It  is  this  tired  feeling  which  is  to  be 
held  responsible  for  the  fact  that  so  many  patients  are  erroneously 
treated  for  neurasthenia  and  psychasthenia,  or  for  a  "nervous  break- 
down" for  a  long  time  till  the  true  nature  of  the  disease  is  finally 
ascertained. 

Anorexia  is  an  inconstant  and  variable  symptom  of  incipient 
phthisis.  In  some,  especially  in  youthful  subjects,  it  is  very  frequent 
and,  coupled  with  anemia,  constipation,  etc.,  is  the  cause  why  so 
many  are  treated  for  chlorosis,  gastritis,  etc.  There  are  many  cases 
in  which  the  appetite  is  well  retained  and,  when  not  "dieted"  with  a 
view  of  improving  nutrition  and  digestion,  but  urged  to  eat  well  and 
plenty  of  the  foods  they  are  accustomed  to  eat,  they  do  not  lose  in 
weight,  but  may  gain  even  when  the  process  in  the  lung  goes  on  actively. 

But  in  the  majority  of  cases  a  persistent  loss  of  weight  is  noted  at 
this  period.  In  some  it  is  slow,  only  one  pound  per  week  on  the  aver- 
age, while  in  others  it  is  more  rapid  and  during  the  first  two  months 
fifteen  or  twenty  pounds  may  be  lost. 

The  activity  of  the  process  is  best  estimated  by  the  fever,  which  is 
never  absent.  It  may  be  slight,  only  1°  elevation  in  the  afternoon  but 
it  can  be  found  in  every  case  by  the  judicious  use  of  the  thermometer. 
A  subnormal  temperature  during  the  early  morning  hours,  best  looked 
for  by  taking  it  per  rectum  before  the  patient  leaves  his  bed,  is  very 
frequently  observed  and  of  immense  diagnostic  significance.  In  many 
the  fever  subsides  when  the  patient  is  kept  in  bed  for  a  couple  of  days 
but  reappears  as  soon  as  some  exercise  is  allowed.  In  those  with 
an  apparently  normal  temperature,  fever  may  be  provoked  by  walking 
or  any  other  form  of  exercise,  as  was  already  discussed  in  detail  (see 
page  172).  In  women,  the  fever  may  appear  only  during  the  menstrual 
period  or  a  few  days  before. 

In  a  large  number  of  cases  pyrexia  is  considerable  even  at  this 
early  stage,  up  to  102°  or  103°  F.  in  the  afternoon  and  evening  and, 
measured  by  comparison  with  the  subnormal  temperature  in  the 
early  morning  hours,  it  is  quite  high.  The  "reversed  type"  of  fever 
with  a  rise  in  the  morning  is  occasionally  seen. 

A  significant  diagnostic  point  is  that  with  high  fever  the  patient 
may  not  be  prostrated  as  is  the  case  with  adults  who  have  fever  due 
to  other  causes.  Moreover,  the  patient  may  have  a  fair,  even  a  good 
appetite,  despite  the  fact  that  the  thermometer  registers  102°  or  103° 
F.,  which  is  very  rare  in  fevers  due  to  other  causes.  During  the 
afternoon  access  of  the  fever,  the  patient,  otherwise  pale,  becomes 
flushed,  often  only  one  cheek  is  red,  he  is  tired  and  disinclined  to 
work.    But  he  may  keep  on  working,  as  was  already  stated. 


INCIPIENT  PHTHISIS  311 

Nightsweats  make  their  appearance  in  a  large  proportion  of  cases 
at  this  stage.  In  some  they  are  sHght,  while  in  others  I  have  met 
with  profuse  nightsweats  during  the  first  two  weeks  of  active  symp- 
toms. They  perspire  also  at  the  least  exertion  or  excitement  and 
during  a  medical  examination  it  is  not  rare  to  see  large  drops  of  sweat 
dribbling  dowm  the  sides  of  the  chest  from  the  axillae.  A  constant 
accompaniment  of  fever  in  incipient  cases  is  tachycardia.  A  case  of 
active  phthisis  with  a  pulse  rate  below  80  per  minute  is  exceedingly 
rare.  In  some  the  heart  action  is  so  rapid  that  they  are  treated  for 
heart  disease  or  for  hyperthyroidism  in  case  the  thyroid  is  enlarged, 
which  is  not  rare,  especially  in  youthful  individuals.  While  in  the 
early  morning  after  a  refreshing  sleep,  the  pulse  rate  may  be  normal, 
the  least  exertion  or  excitement  will  raise  it  up  to  90,  100  or  more. 
Instability  of  the  pulse  is  characteristic  of  phthisis.  In  youthful 
subjects  the  tachycardia  is  apt  to  be  more  pronounced  than  in 
persons  over  twenty-five  years  of  age.  The  blood-pressure  is 
low  and  a  registration  less  than  70  mm.  of  mercury  is  quite 
common. 

Symptoms  referable  to  the  respiratory  system  may  not  be  seen  at 
this  stage  excepting  the  cough  and  at  times  the  intermittent  hoarseness, 
which  is  usually  due  to  a  laryngeal  catarrh,  or  pressure  on  the  laryngeal 
nerve,  and  hardly  ever  to  infiltration  of  the  larynx.  At  times  we  see 
patients  who  suffer  from  more  or  less  pronounced  pains  in  the  chest, 
especially  under  the  scapula  or  in  the  shoulder. 

Hemoptysis  is  quite  frequent  at  this  stage.  As  was  already  stated, 
statistics  taken  of  large  numbers  of  patients  show  that  about  10  per 
cent,  of  cases  begin  with  hemorrhage.  They  are  the  lucky  ones, 
because  this  clears  up  the  case  and  proper  measures  are  promptly 
taken.  But  many  of  these  initial  hemorrhages  were  actually  preceded 
by  a  train  of  symptoms,  such  as  fever,  tachycardia,  etc.,  to  which  the 
patient  paid  no  attention.  However,  in  about  25  per  cent,  of  cases 
more  or  less  blood-spitting  occurs  at  the  time  the  disease  is  recog- 
nized. It  may  be  only  blood-tinged  sputum,  a  mouthful  or  two  of 
blood,  or  even  a  profuse  hemorrhage.  It  will  bear  repetition  that 
these  hemorrhages  are  practically  never  fatal. 

Physical  Signs. — With  any  or  all  of  these  symptoms  a  diagnosis  of 
incipient  tuberculosis  should  not  be  made  unless  physical  exploration 
of  the  chest  discloses  a  localized  lesion  in  the  lungs. 

Inspection. — Inspection  yields  excellent  diagnostic  criteria  in  most 
cases  at  this  early  stage.  Inasmuch  as  most  of  the  incipient  cases 
are  really  recrudescences  of  old  quiescent  lesions  dating  back  to  child- 
hood, we  find  in  many  atrophy  of  the  muscles  over  the  site  of  the 
lesion.  The  sternocleidomastoid,  the  scaleni  and  trapezius,  etc.,  may 
be  smaller  than  those  on  the  opposite  side  and  softer,  or  even  flabby 
to  the  touch.  This  is  more  important  to  look  for  than  the  form  of  the 
chest  which  may  be  normal,  flat,  rachitic,  etc.,  without  influencing  the 
diagnosis.    With  the  atrophy  of  the  muscles  there  is  usually  seen  a 


312  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

slight  shoulder-droop  and  an  excavation  of  the  supraclavicular  or 
supraspinous  fossa,  or  at  least  some  flattening  and  defective  motion  or 
lagging  of  the  part  of  the  chest  harboring  the  lesion.  This  asymmetry, 
flattening  and  lagging  is  very  easy  to  detect  if  carefully  looked  for 
and  is,  when  found,  of  immense  diagnostic  importance,  provided 
occupational  influences  are  excluded. 

In  more  recent  lesions,  or  when  an  old  lesion  exists  in  one  side  but 
the  outbreak  of  phthisis  is  due  to  a  new  lesion  in  the  opposite  side, 
which  is  very  frequent,  we  find  the  muscles  over  the  site  of  the  active 
new  infiltration  are  tense  and  rigid,  standing  out  prominently.  But 
this  is  after  all  not  very  frequent,  which  goes  to  show  that  most  of 
the  incipient  cases  are  really  due  to  reawakening  of  old  smoldering 
tuberculous  processes  in  the  lung. 

Percussion. — ^As  was  already  stated,  there  are  very  few  cases  of  active 
incipient  tuberculosis  in  which  no  signs  of  an  infiltration  can  be  dis- 
covered by  careful  and  gentle  percussion.  We  almost  invariably  find 
some  airless  pulmonary  tissue  or  shrinkage  of  one  apex  manifesting 
itself  by  a  short  note  or  by  pulmonary  retraction.  The  height  of  the 
apex  may  be  less  than  that  of  its  mate  on  the  opposite  side,  or  its  width 
may  be  less,  as  determined  by  Kronig's  method  of  percussion.  We 
may  also  find,  though  not  as  often  as  Kronig  believed,  that  the  base 
on  the  affected  side  is  somewhat  retracted. 

In  my  own  experience,  percussion  signs  are  more  often  found  over 
the  posterior  aspects  of  the  apices  than  anteriorly.  While  over  the 
supraclavicular  region  we  may  find  that  the  width  of  the  resonant 
area  is  less  than  that  of  the  other  side,  it  is  easier  and  less  time-con- 
suming to  map  out  the  mesial  lines  of  demarcation  between  resonance 
and  dulness  in  the  supraspinous  fossae,  and  over  the  site  of  the  lesion 
this  line  is  usually  dislocated  outward. 

It  is  also  easily  ascertained  whether  the  height  of  the  apices  poste- 
riorly shows  any  asymmetry.  At  a  very  early  stage  we  find  that  while 
over  the  unaffected  apex  the  resonance  reaches  as  far  as  the  interval 
between  the  seventh  cervical  and  first  thoracic  spines,  that  of  the 
affected  apex  is  much  lower.  I  have  found  these  changes  at  times 
before  any  auscultatory  signs  made  their  appearance. 

The  changes  in  pitch,  duration  and  intensity  of  the  note  obtained  at 
this  stage  are  of  less  significance  than  those  of  shrinkage  just  spoken  of, 
and  they  depend  too  much  on  the  personal  equation  of  the  observer 
to  have  important  clinical  bearings.  Thus,  we  often  find  that  a  con- 
tracted apex  is  altogether  hyperresonant  or  even  tympanitic  on  per- 
cussion, and  by  comparison  the  unaffected  side  appears  to  emit  a  defec- 
tive note.  The  stories  told  in  text-books  about  two  equally  competent 
clinicians  localizing  an  apical  lesion  by  percussion  and  each  finding 
it  in  another  side  are  undoubtedly  based  on  these  facts.  It  is  generally 
due  to  faulty  interpretation  of  tympany  caused  by  relaxation  and 
hyperfunction  of  the  lung  tissue  around  conglomerations  of  tubercles, 
as  has  already  been  shown.    The  discordance  may  also  be  due  to  an 


INCIPIENT  PHTHISIS  313 

old  and  cicatrized  lesion  on  one  side,  while  the  new  and  active  lesion 
is  in  the  opposite  side  of  the  chest. 

Of  greater  importance  is  respiratory  percussion.  The  patient  is 
asked  to  inspire  or  expire  and  hold  his  breath,  and  we  percuss  during 
each  phase  of  respiration.  In  health  the  note  is  clearer  during  full 
and  held  expiration,  while  over  an  infiltrated  apex  a  long  and  held 
inspiration  gives  a  duller  note  than  found  over  the  opposite  unaffected 
side. 

Of  the  various  seats  of  election  of  dulness  in  incipient  phthisis  which 
have  been  described  by  Lees,^  Riviere,^  and  others,  the  sites  I  have  been 
able  to  find  impaired  in  most  cases  at  a  very  early  stage  are  the  supra- 
spinous fossae  near  the  spine  and  beneath  and  above  the  inner  third 
of  the  clavicle.  Persistent,  impaired  resonance  in  any  of  these  places, 
when  accompanied  by  constitutional  symptoms  of  phthisis,  is  of  great 
diagnostic  significance.  Impaired  resonance  elicited  with  hooked- 
finger  percussion  between  the  heads  of  the  sternocleidomastoid 
immediately  above  the  clavicle  on  one  side  is  very  often  found. 

Auscultation. — It  is  not  generally  appreciated  that  the  earliest 
changes  in  the  respiratory  sounds  in  phthisis  are  modifications  of 
the  inspiratory  murmur,  while  changes  in  the  expiratory  murmur 
usually  indicate  a  more  or  less  advanced  stage  of  the  disease.  At  a 
very  early  period  of  the  disease  the  inspiratory  murmur  loses  its  soft, 
breezy  character  and  becomes  rough  or  granular,  an  indication  of  par- 
tial stenosis  of  the  bronchioles  supplying  the  affected  part  of  the  lung 
or  unequal  respiratory  movement  of  the  infiltrated  lung  area.  In 
many  cases  the  inspiratory  murmur  is  feeble,  at  times  even  absent, 
over  a  limited  area  corresponding  to  the  area  of  impaired  resonance, 
while  the  whispered  voice  is  transmitted  clearly.  But  the  most  com- 
mon sign  of  an  early  lesion  is  interrupted  or  cog-wheel  breathing,  the 
inspiratory  sound  is  broken  up  into  several  parts  so  that  it  appears 
jerky.  Either  of  these  types  of  altered  inspiratory  murmur  may  be 
audible  long  before  the  expiratory  murmur  is  in  any  way  changed. 

The  most  common  seats  of  the  changed  breath  sounds  are  poste- 
riorly near  and  above  the  spine  of  the  scapula,  the  "alarm  zone"  of 
Sergent,^  and  rarely  in  front  immediately  beneath  the  inner  third  of 
the  clavicle.  It  is  located  posteriorly  as  follows:  From  the  centre 
of  the  space  separating  the  spinous  process  of  the  seventh  cervical 
from  that  of  the  first  thoracic,  a  line  is  drawn  as  far  as  the  tubercle  of 
the  trapezium  on  the  spine  of  the  scapula.  From  the  middle  of  this 
line,  taken  as  a  centre,  a  circle  is  described  with  a  diameter  equal  to 
that  of  a  silver  dollar.  The  circumference  of  this  circle  forms  the 
boundary  of  the  "zone  of  alarm"  (Fig.  65).  When  heard  at  any  of 
these  points  during  ordinary  breathing,  and  repeatedly  found  on 
several  examinations,  not  decreasing  in  intensity  but  on  the  contrary 

1  Brit.  Med.  Jour.,  1912,  ii,  1268. 

2  Early  Diagnosis  of  Tubercle,  London,  1914,  p.  25. 

3  Le  monde  Medical,  1913,  xxii,  1121;    La  Clinique,  1913,  viii,  437. 


314 


CHRONIC  PHTHISIS— INCIPIENT  STAGE 


becoming  more  and  more  pronoimced,  rough  and  cog-wheel  breathing 
are  good  signs  of  incipient  infiltration  of  an  apex,  provided  of  course, 
that  the  constitutional  symptoms  show  activity;  otherwise  they  may 
be  indications  of  an  old  and  cicatrized  lesion.  We  have  already  stated 
that  at  times  feeble  breath  sounds  are  found;  they  may  be  of  a  blow- 
ing or  even  of  a  bronchial  character,  and  some  crackling  may  be 
audible  at  the  end  of  inspiration. 

Rales  are  not  heard  at  all  over  really  incipient  lesions.  Occasionally 
some  sibilation  is  audible,  but  this  is  usually  transitory  and  disappears 
after  the  patient  takes  a  deep  breath.    At  most,  some  dry  crackling 


Fig.  65. — 1,  The  "alarm  zone;"    ^,  the  space  between  the  spinous  processes  of  the 
seventh  cervical  and  first  dorsal  vertebrae;  3,  the  tubercle  of  the  trapezius. 


may  be  brought  out  when  the  patient  coughs  vigorously.  When  crepi- 
tant and  especially  moist  subcrepitant  rales  are  audible,  we  are  dealing 
with  an  extensive  lesion  of  some  duration. 

In  some  cases  we  hear  at  a  very  early  stage  during  expiration  a 
hemic  murmur  originating  in  the  subclavian  artery  and  ascribed  to 
kinking  of  that  vessel  by  the  tuberculous  infiltration  or  by  shrinking 
lung.  But  it  is  by  no  means  pathognomonic  of  phthisis  because  it  is 
heard  in  many  apparently  healthy  persons. 

The  whispered  voice  is  very  often  transmitted  more  or  less  clearly 
over  consolidated  areas  of  lung  tissue  and  when  heard  when  the  chest- 


INCIPIENT  PHTHISIS  315 

piece  of  the  stethoscope  is  pressed  firmly  over  the  skin  of  the  chest,  it 
is  of  the  same  diagnostic  significance  as  impaired  resonance,  with 
which  it  usually  runs  parallel,  as  has  been  pointed  out  by  Sewall.^ 

To  be  of  diagnostic  significance  in  early  phthisis,  the  auscultatory 
signs  must  be  localized  over  one  apex,  circumscribed,  fixed  and  per- 
sistent for  some  time,  and  not  influenced  by  cough  and  strong  respira- 
tory efforts,  excepting  clicks  and  rales  which  may  be  brought  out  by 
cough.  Evanescent  changes  in  resonance  and  breath  sounds  may  be 
found  in  many  apparently  healthy  persons.  It  is  for  this  reason  that 
many  who  attempt  to  make  a  final  diagnosis  of  incipient  phthisis 
during  one  examination  meet  with  so  many  failures. 

Elements  of  Diagnosis  of  Incipient  Phthisis. — Just  as  the  general 
and  constitutional  symptoms,  such  as  cough,  fever,  tachycardia,  ema- 
ciation, etc.,  are  insufficient  to  decide  a  case  till  the  lesion  is  localized 
in  the  lung,  so  are  the  signs  obtained  by  physical  exploration  of  the 
chest  inadequate,  even  when  marked,  to  prove  that  we  are  dealing  with 
a  case  of  active  incipient  phthisis.  Only  the  combination  of  both  groups 
of  clinical  data  gives  solid  support  for  diagnostic  inferences.  A  skilled 
diagnostician  may  easily  diagnosticate  a  case  of  advanced  phthisis 
by  looking  at  the  pathognomonic  facies  of  the  patient,  from  the  his- 
tory and  course  of  the  disease,  or  from  auscultatory  findings  alone, 
and  only  rarely  err.  But  in  incipient  phthisis  it  is  the  correlation  of 
all  available  clinical  data,  the  history,  the  symptomatology  and  course 
of  the  disease,  combined  with  the  findings  of  physical  exploration  of 
the  chest  that  can  be  expected  to  clinch  the  diagnosis. 

The  signs  enumerated  above — defective  resonance,  narrowing  of  the 
resonant  areas  over  one  apex,  feeble,  rough,  granular  or  cog-wheel 
breathing,  or  even  rales,  may  each  be  found  in  persons  of  excellent 
health,  at  least  such  as  are  not  actively  tuberculous.  This  is  because 
old  and  healed  lesions,  tuberculous  and  others,  leave  traces  behind 
them  which  alter  permanently  the  air  content  of  the  pulmonary  par- 
enchyma and  diagnostic  methods  in  vogue  disclose  these  conditions. 

Sources  of  Errors. — I  am  not  prepared  to  state  that  the  proportion 
of  diagnostic  errors  made  while  attempting  to  recognize  phthisis  in  its 
very  incipiency  is  greater  than  in  other  diseases ;  in  fact,  I  am  convinced 
that  it  is  not.  But  in  phthisis,  owing  to  its  great  prevelance  and  its 
social  aspects,  as  well  as  its  insidious  onset,  the  opportunities  for 
making  mistakes  are  immense.  It  is  for  this  reason  that  the  sources 
of  error  must  be  emphasized. 

Bias  is  more  often  a  source  of  error  in  phthisis  than  in  any  other 
disease.  Especially  is  this  the  case  when  there  is  a  history  of  exposure 
to  infection.  To  my  mind  this  is  one  of  the  greatest  fallacies  we  have 
to  cope  with.  It  must  always  be  remembered  that  in  large  industrial 
cities  everyone  is  exposed  to  infection  and  is,  in  fact,  infected  with 
tubercle  bacilli  before  he  passes  his  fifteenth  year.     On  the  other 

1  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  2027. 


Sl6  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

hand,  marital  phthisis  is  less  frequent  than  would  be  expected  if  every 
adult  exposed  to  tuberculosis  would  become  phthisical.  Excepting 
in  young  children  a  case  must  therefore  be  judged  on  its  clinical 
manifestations  and  not  on  the  fact  that  the  patient  came  into  contact 
with  a  consumptive. 

Tubercle  Bacilli. — The  diagnosis  of  phthisis  is  clinched  by  the 
finding  of  tubercle  bacilli  in  the  sputum,  but  is  not  at  all  excluded  by 
negative  bacteriological  findings.  Unfortunately,  too  many  wait 
rather  long  for  the  bacilli,  thus  losing  valuable  time  which  often  can- 
not be  reclaimed  by  any  known  means.  Phthisis  begins  as  an  infiltra- 
tion, and  only  when  softening  had  taken  place  and  the  products  of 
tissue  disintegration  are  eliminated  through  a  bronchus,  can  tubercle 
bacilli  be  found  in  the  sputum.  Under  the  circumstances,  waiting  for 
tubercle  bacilli  to  make  their  appearance  in  the  sputum  is  just  as 
hazardous  as  waiting  for  pus  to  make  its  appearance  through  a  fistula 
or  sinus  before  making  a  diagnosis  of  a  tuberculous  joint. 

On  rare  occasions  there  are  errors  of  quite  a  different  nature. 
Tubercle  bacilli  may  be  found  in  the  sputum  of  persons  who  are  not 
actively  tuberculous.  Of  course,  from  the  practical  standpoint  tubercle 
bacilli  in  sputum  are  an  indication  that  they  are  in  all  probabilities 
derived  from  a  tuberculous  lesion  in  the  lower  respiratory  tract.  But 
in  New  York  City  we  meet  with  numerous  persons  who  have  reports 
from  some  private  as  well  as  from  the  municipal  laboratory  stating 
that  the  sputum  of  the  bearer  has  been  examined  and  found  to  con- 
tain tubercle  bacilli.  Yet,  without  any  treatment  or  special  care,  they 
have  kept  at  work  for  years  and  felt  well.  Indeed,  many  cases  are 
admitted  to  sanatoriums  solely  on  the  strength  of  positive  sputum 
findings,  to  be  declared  non-tuberculous  after  careful  observation. 

The  reasons  for  this  anomaly  are  to  be  sought  for  in  several  facts 
which  have  not  been  emphasized  as  strongly  as  they  deserve.  I  have 
no  doubt  that  in  busy  laboratories  mistakes  are  liable  to  happen  in 
handling  the  sputum  bottles,  in  numbering  the  slides,  or  while  enter- 
ing the  findings  in  the  reports.  In  banks  where  the  clerks  are  just  as 
careful  as  laboratory  workers,  mistakes  occur  at  times.  Even  conced- 
ing that  the  number  of  such  mistakes  is  comparatively  negligible,  in 
the  individual  cases  it  may  count  very  much. 

We  have  already  spoken  of  the  acid-fast  rods  which  simulate  tubercle 
bacilli  and  which  are  found  in  butter  and  milk,  on  graminacea,  in  the 
soil,  in  dung  and  inanure,  and  even  in  tap  water  supplied  through  metal 
pipes.  These  bacilli  are  dead,  or  non-pathogenic  to  guinea-pigs,  but 
they  give  the  usual  staining  reactions.  Then  we  may  have  the  smegma 
bacilli  which  have  been  mistaken  for  tubercle  bacilli  and  thus  have 
led  to  erroneous  diagnosis  and  extirpation  of  healthy  kidneys.  There 
are  also  the  acid-fast  lepra  bacilli,  the  microorganisms  which  greatly 
resemble  them  and  are  found  in  the  secretion  of  the  mucous  mem- 
brane of  the  nose,  also  the  acid-fast  rods  found  in  the  saliva  and  the 
secretions  in  cases  of  bronchitis  and  pulmonary  gangrene.    L.  Napo- 


INCIPIENT  PHTHISIS  317 

leon  Boston^  found  acid-fast  bacilli  in  patients  suffering  from  acute 
colds  and  influenza,  and  disappearing  during  convalescence.  But 
most  of  these  microorganisms  are  difficult  to  differentiate  from  tubercle 
bacilli  microscopically,  through  culture  and  animal  inoculation. 

It  has  recently  been  found  that  the  spores  of  lycopodium  are  acid- 
fast,  so  that  persons  taking  pills  covered  by  that  substance  may  impart 
some  of  it  to  the  sputum  and  thus  lead  to  error. 

There  is  a  possibility  that  the  acid-fast  rods  or  specks  found  in  the 
sputum  may  not  have  been  there  before  it  left  the  bronchial  tubes  and 
trachea,  but  got  into  the  sputum  while  it  was  passing  through  the 
pharynx,  mouth  or  lips,  especially  in  persons  living  in  houses  inhabited 
by  careless  consumptives.  It  is  also  important  to  mention  that  ordi- 
nary smear  preparations  are  less  likely  to  lead  to  errors  of  this  sort  than 
the  antiformin  method. 

To  be  sure,  the  most  reliable  sign  of  phthisis  is  tubercle  bacilli  in 
the  sputum,  and  I  do  not  at  all  intend  to  underestimate  its  far-reaching 
significance.  Statistically,  the  chances  of  error  are  undoubtedly 
insignificant,  and  a  laboratory  may  be  proud  that  among  several 
thousands  of  specimens,  only  half  a  dozen  mistakes  have  been  made. 
But  the  practising  physician  does  not  treat  his  patient  statistically. 
In  the  individual  case  it  is  well  to  bear  in  mind  the  possibility  of  errors 
of  this  kind,  especially  in  cases  in  which  the  disease  does  not  pursue 
the  course  expected  in  some  form  of  phthisis. 

Skiagraphy, — Skiagraphy  has  been  discussed  in  detail  in  Chapter 
XVII. 

The  Tuberculin  Tests, — The  changed  reactivity  to  tuberculin  which 
is  observed  in  organisms  infected  with  tubercle  bacilli,  which  manifests 
itself  mainly  by  hypersensitiveness  to  that  agent,  has  been  applied 
in  the  diagnosis  of  doubtful  cases,  especially  in  sanatoriums.  When 
first  introduced  it  was  heralded  as  specific  and  it  was  asserted  that 
finally  a  positive  and  uncontrovertible  test  had  been  found  which 
decides  whether  or  not  an  individual  is  suffering  from  active  tuber- 
culosis. 

For  diagnostic  purposes,  tuberculin  is  applied  in  various  ways.  It 
is  introduced  directly  into  the  circulation  by  the  subcutaneous  method ; 
into  the  lymph  spaces  by  the  cutaneous  method,  or  applied  to  mucous 
membranes  for  normal  absorption  by  the  conjunctival  method.  It 
has  thus  been  applied  to  the  skin,  mucous  membrane,  and  subcuta- 
neously.  The  subcutaneous  application  produces  general  and  consti- 
tutional symptoms  of  tuberculin  intoxication,  while  the  others  produce 
local  effects. 

Clinically  the  following  reactions  are  evoked  by  the  tuberculin 
test : 

1.  General  reaction,  manifesting  itself  after  the  subcutaneous  injec- 
tion of  tuberculin  by  fever,  chilliness,  malaise,  headache,  backache,  etc. 

1  Interstate  Medical  Journal,  1914,  xxi,  330. 


318  CHRONIC  PHTHISIS^INCIPIENT  STAGE 

2.  Focal  reaction,  consisting  in  congestive  and  inflammatory  phe- 
nomena in  the  neighborhood  of  the  tuberculous  lesion. 

3.  Local  reactions,  hyperemia  and  inflammatory  phenomena  at  the 
site  of  the  tuberculin  application.  Of  these  there  are:  (a)  The  cuta- 
neous reaction  of  von  Pirquet  and  se-veral  of  its  modifications;  (b) 
mucous  membrane  reactions,  such  as  the  opthalmoreaction  of  Calmette 
and  Wolff-Eisner,  etc.,  and  many  others  which  have  been  discarded 
for  valid  reasons. 

The  Cutaneous  Tuberculin  Test. — This  is  the  simplest  and  unquestion- 
ably the  harmless  method  of  application  of  tuberculin  for  diagnostic 
purposes.  It  is  usually  performed  on  the  inner  surface  of  the  fore- 
arm, though  any  part  of  the  body  may  d^o,  but  it  appears  that  the 
skin  of  the  trunk  is  not  as  sensitive  as  that  of  the  forearm  and  thigh. 
The  skin  is  cleaned  with  alcohol  or  ether,  and  a  drop  of  pure  tuberculin 
is  applied.  A  suitable  instrument  is  then  used  to  make  two  abrasions, 
one  about  two  inches  away  from  the  spot  where  the  tuberculin  has 
been  applied,  and  the  other  over  the  tuberculin.  The  instrument 
devised  by  von  Pirquet  may  be  used.  It  consists  of  a  heavy  handle 
with  a  spade-like  platinum  end  which  is  more  or  less  sharp  and  used 
for  the  purpose  of  scratching  or  boring  a  cup-like  depression  in  the 
skin.  It  is  important  that  bleeding  should  not  be  caused,  but  only 
the  superficial  layer  of  the  skin  is  scraped  away,  so  as  to  open  the 
lymph  spaces  and  thus  favor  absorption  of  the  tuberculin.  A  needle 
may  be  used  for  the  purpose  or  even  the  point  of  a  scalpel,  making  one 
or  two  parallel  incisions  through  the  superficial  layer  of  the  skin.  I 
have  found  it  just  as  effective  to  make  the  abrasion  first  and  then 
apply  the  tuberculin  with  a  toothpick,  rubbing  it  vigorously,  i^fter 
five  minutes  the  excess  of  tuberculin  is  wiped  away  with  some  cotton 
and  the  patient  allowed  to  go  without  any  dressing. 

If  the  test  turns  out  negative,  it  will  be  seen  that  twenty-four  hours 
later  the  two  abrasions  either  heal  in  the  same  manner,  or  when  a 
scab  is  formed  it  is  of  the  same  appearance  on  both  abrasions.  When 
positive,  the  control  appears  healed,  or  showing  a  slight  scab,  while 
the  abrasion  to  which  tuberculin  has  been  applied  shows  an  inflamma- 
tory infiltration  manifesting  itself  as  a  slightly  elevated,  red  papule. 
This  reaction  usually  appears  twelve  to  twenty-four  hours  after  the 
application  of  the  tuberculin;  on  rare  occasions  it  is  premature, 
appearing  within  four  to  six  hours,  and  may  disappear  soon,  or  remain 
for  days;  or  it  may  be  late  in  appearing,  even  a  delay  of  a  week  has 
been  observed  in  rare  cases. 

The  reaction  may  be  slight,  showing  some  redness  with  infiltration, 
or  a  more  extensive  area  of  redness  with  an  appreciably  raised  papule. 
In  some  cases  the  red  area  is  very  extensive,  simulating  erysipelas  and 
the  papule  is  very  elevated.  Quite  often  the  first  test  results  in  a 
negative  outcome,  but  a  second  application,  about  a  week  later, 
gives  positive  results.  It  is  therefore  advisable  to  repeat  the  test 
two  or  three  times  before  pronouncing  it  unequivocally  negative. 


PLATE  XII 


■'^Se 


Cutaneous  Tuberculin  Reaction  of  v.  Pirquet. 
(Taken  from  Hamill.) 


INCIPIENT  PHTHISIS  319 

These  "secondary"  reactions  are  usually  very  intense,  although 
the  first  application  was  negative.  It  has  also  been  noted  that  the 
tuberculin  sensitiveness  is  often  increased  by  a  second  or  third  inocu- 
lation and  the  area  at  which  the  first  inoculation  was  made  also  reacts. 
Attempts  to  utilize  these  facts  for  diagnostic  purposes  have  not  been 
encouraging. 

Significance  of  the  Cutaneous  Tuberculin  Reaction.  —  Clinical  expe- 
rience has  shown  conclusively  that  persons  who  have  at  any  time  been 
infected  with  tubercle  bacilli  react  to  the  cutaneous  tuberculin  test; 
experimental  investigations  have  confirmed  it.  It  is  immaterial 
whether  the  infection  is  followed  by  clinical  manifestations  of  disease, 
or  not;  whether  the  tuberculous  lesion  is  active  or  quiescent,  the  result 
is  the  same.  It  appears  to  me,  however,  that  we  do  not  have  sufficient 
evidence  for  a  conclusion  as  to  the  question  how  long  after  a  lesion 
has  healed  does  the  skin  remain  sensitive  to  tuberculin.  Assuming 
that  no  tuberculous  lesion  ever  heals  perfectly,  which  has  not  yet  been 
proved,  we  accept  that  even  healed  lesions  act  in  this  way. 

New-born  infants  never  react  to  tuberculin,  but  when  living  in 
tubercle-laden  surroundings  they  soon  show  the  hypersensitiveness, 
as  was  already  shown  (page  58).  Inasmuch  as  over  90  per  cent,  of 
humanity  have  been  infected  before  reaching  the  twentieth  year  of 
life,  we  find  that  many  show  positive  reactions  to  tuberculin. 

It  is  thus  clear  that  for  clinical  purposes,  when  we  look  for  evidences 
of  active  phthisis,  this  test  is  of  little  value,  because  it  shows  not  only 
those  who  suffer  from  active  tuberculosis,  but  also  such  as  have  latent 
or  healed  lesions.  Moreover,  it  is  negative  in  rapidly  progressing  pul- 
monary tuberculosis,  in  tuberculous  meningitis,  in  acute  miliary  tuber- 
culosis and  also  in  the  terminal  stages  of  chronic  phthisis,  when  the 
formation  of  antibodies  is  slackened  or  abolished.  It  has  also  been 
found  negative  in  the  presence  of  other  infectious  diseases,  like  measles, 
scarlet  fever,  diphtheria,  etc.,  in  some  cases  of  pneumonia,  and  often 
during  pregnancy.  In  a  certain  number  of  cases  of  undoubted  phthisis 
the  cutaneous  reaction  was  found  negative  without  any  assignable 
reason;  von  Pirquet  estimated  it  at  from  2  to  4  per  cent.,  but  in  my 
experience  it  is  more  than  double  that  proportion. 

After  many  years  of  experience  with  this  test  it  was  concluded  by 
most  authors  that  a  positive  cutaneous  reaction  is  of  clinical  value 
only  in  children,  and  that  the  younger  the  child,  the  more  its  clinical 
significance.  But  from  more  extensive  experience  it  appears  that  it 
is  also  unreliable  in  children.  From  personal  experience  I  am  inclined 
to  the  conclusion  that  children  between  three  and  fifteen  years  of 
age  with  a  positive  tuberculin  reaction  are  not  necessarily  doomed  to 
develop  active  phthisis;  I  have  even  observed  many  infants  under 
two  years  of  age  grow  into  healthy  children  in  spite  of  the  positive 
outcome  of  the  test,  and  the  statement  of  some  authors  to  the  effect 
that  an  infant  under  one  year  showing  a  positive  cutaneous  reaction 
will  not  survive  a  year  is  negated  by  the  many  infants  I  observed 


320  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

and  reported  elsewhere/  who  have  thrived  despite  the  fact  that  during 
the  first  six  months  of  their  Hfe  the  reaction  was  positive. 

Specificity  of  the  Test. — It  appears  that  from  the  scientific  standpoint 
the  specificity  of  the  test  has  not  been  proved  to  the  satisfaction  of  all, 
as  has  already  been  shown.  Autopsy  findings  by  Ganghofner,  Rad- 
ziejewski,  Behrend,  Bruckner,  Reiischel,  and  many  others  show  that 
there  are  cases  in  which  the  test  was  positive,  yet  no  tuberculous 
lesions  were  found  at  the  autopsy,  and  the  reverse.  Experimentally 
the  evidence  is  in  the  same  direction  (see  p.  32). 

It  has  also  been  found  that  tuberculin  is  not  the  only  substance 
capable  of  producing  a  positive  skin  reaction  in  tuberculous  individuals, 
but  that  other  toxins  when  inoculated  into  the  skin  often  produce 
changes  which  are  akin  to  the  tuberculin  reaction.  Holly"  found 
that  the  skin  reacted  when  inoculated  with  the  toxins  of  dysentery, 
typhoid,  paratyphoid,  pyocyaneous,  cholera,  etc.  Just  as  with  tuber- 
culin, these  toxins  were  always  negative  in  very  young  infants,  and  in 
children  suffering  from  acute  infectious  diseases,  as  scarlet  fever, 
measles,  etc.,  becoming  positive  during  convalescence.  The  controls, 
performed  with  carbol-glycerin,  were  always  negative.  In  short,  these 
non-tuberculous  toxins  showed  all  the  characteristics  of  tuberculin 
when  inoculated  into  the  human  skin.  That  any  or  all  of  these  toxins 
acted  in  an  anaphylactic  or  specific  manner  may  be  ruled  out  because, 
with  the  exception  of  tuberculosis,  the  individuals  tested  never  suffered 
from  typhoid,  paratyphoid,  cholera,  diphtheria  or  pyocyaneous  sepsis. 
Tenzer^  obtained  skin  reactions  indistinguishable  from  those  of  the 
von  Pirquet  test  with  cholera  vaccine  and  with  a  mixture  of  pepto- 
albumoses,  in  persons  in  whom  the  tuberculin  test  was  positive. 

From  these  experiments,  as  well  as  from  those  performed  by  Sorgo,^ 
it  appears  that  tuberculous  individuals  react  with  a  specific  intensity 
to  tuberculin  and  to  other  toxins,  thus  indicating  that  it  is  mainly  due 
to  hypersensitiveness  of  the  skin.  The  assumption  that  the  skin  of 
the  tuberculous  is  endowed  with  a  specific  allergy  to  tuberculin  alone 
is  thereby  disproved.  The  allergy  is  evidently  a  cutaneous  hypersen- 
sitiveness to  the  action  of  toxins  in  general.  Hamburger,^  one  of  the 
most  authoritative  champions  of  the  specificity  of  the  tuberculin 
test,  after  inoculating  tuberculous  patients  with  substances  similar  to 
those  with  which  tuberculin  is  prepared  (glycerin,  bouillon,  extractives, 
salts,  etc.)  became  convinced  that  the  cutaneous  reaction  is  due  more 
to  the  latter  substances  than  to  the  tuberculin  which  acts  merely  as  a 
skin  irritant. 

We  are  therefore  justified  in  concluding  that  we  are  far  from 
having  sufficient  and  satisfactory  information  to  speak  with  certainty 

1  See  A  Study  of  the  Child  in  the  Tuhorculou.s  MiHou,  Arch,  uf  Pediatries,  1914, 
xxxi,  96,  197;  1915,  xxxii,  20. 

2  Miineh.  med.  Woeh.,  1911,  Iviii,  12«5. 

3  Monatsschr.  f.  Kinderheilkunde,  1911,  x,  131. 
''  Deut.  med.  Wchnschr.,  1911,  xxxvii,  1015. 

5  Die  Tuberkulose  des  Kindesalter,  p.  37. 


PLATE    XllI 


Tuberculin   Ophihalmo-reacLion.     (Taken  from  Citron.) 


INCIPIENT  PHTHISIS  321 

about  the  cutaneous  tuberculin  test  and  its  underlying  causes,  and 
from  the  theoretical  standpoint  its  specificity  has  not  been  proved 
conclusively. 

However,  clinically  the  test  is  important  in  showing  the  wide  dis- 
semination of  tuberculous  infection  among  civilized  humanity,  even 
though  the  same  results  could  be  also  obtained  with  substances  other 
than  tuberculin.  In  children  it  shows  whether  they  have  Been  infected 
with  tuberculosis  and  in  infants  it  even  points  to  active  tuberculosis, 
but  in  adults  it  is  of  no  clinical  value  at  all. 

The  various  modifications  of  the  cutaneous  tuberculin  tests  are  not 
superior  to  the  von  Pirquet  method.  The  Moro  test,  consisting  in  rub- 
bing tuberculin  ointment  into  the  skin  is  of  less  value  than  the  one 
described  above.  The  percutaneous,  the  quantitative  cutaneous  test, 
etc.,  offer  no  advantages  over  the  von  Pirquet  test,  which  is  after 
all  the  simplest  and  most  reliable. 

The  Conjunctival  Reaction. — The  conjunctival  reaction  invented  by 
Calmette  and  Wolff-Eisner,  is  made  by  instilling  into  the  conjunctiva, 
with  an  ordinary  eye  dropper,  one  drop  of  a  1  per  cent,  solution  of 
tuberculin.  The  reaction  appears  within  twelve  hours  and  reaches 
its  optimum  in  twenty-four  hours,  producing  redness  of  the  palpebra, 
and  when  the  reaction  is  intense,  the  redness  is  more  pronounced  and 
there  is  also  injection  of  the  vessels  of  the  eyeball  and  more  or  less 
well-marked  secretion  of  mucus.  It  may  last  for  two  or  three  days. 
Of  course,  in  estimating  the  effects  of  the  tuberculin,  comparison  is 
made  with  the  other  eye. 

Among  clinically  non-tuberculous  persons,  from  10  to  25  per  cent, 
react,  while  among  those  who  are  evidently  tuberculous,  between  50 
and  75  per  cent,  show  a  reaction  with  this  test.  It  has  been  practically 
discarded  of  late  because  in  many  cases  inflammatory  phenomena 
have  appeared  in  the  tested  eye  which  are  quite  troublesome.  In 
one  of  my  cases  the  inflammation  was  so  severe,  persisting  for  three 
months,  that  I  have  ever  since  hesitated  in  applying  it.  Bandelier  and 
Ropke  state  that  experiments  on  animals  have  shown  that  this  test  is 
unreliable  in  cases  of  human  phthisis,  since  the  reaction  may  be  nega- 
tive in  spite  of  the  presence  of  active  tuberculosis  unless  10  per  cent, 
solution  of  tuberculin  is  used,  and  this  should  not  be  done  when 
dealing  with  human  eyes. 

The  Subcutaneous  Tuberculin  Test. — This  is  the  test  preferred  by 
most  of  those  who  have  confidence  in  the  diagnostic  value  of  tuberculin 
in  doubtful  cases.  It  is  claimed  that  it  is  not  only  reliable  in  deciding 
whether  the  patient  has  ever  been  infected  with  tubercle  bacilli,  but 
also  in  showing  whether  the  disease  is  active  and  that  in  many  cases 
it  even  shows  the  area  involved  at  the  time  the  test  is  made  by  the 
so-called  "focal  reaction." 

Of  the  various  ways  in  which  it  is  performed,  the  following  is  the 
simplest  and  gives  the  same  results  as  any  that  has  been  devised: 

For  twenty-four  hours  the  temperature  of  the  patient  is  taken  every 
21 


322  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

three  hours  and  carefully  recorded.  Inquiries  are  made  as  to  the  sub- 
jective symptoms,  especially  pains  in  the  chest,  headache,  cough, 
expectoration,  etc.  An  injection  of  0.1  mg.  of  tuberculin  is  then  made 
subcutaneously  in  the  region  of  the  back  below  the  angle  of  the  scapula, 
or  any  other  place.  Of  course,  all  antiseptic  precautions  are  to  be 
rigidly  observed  and  the  skin  washed  with  alcohol  or  ether.  In  case 
no  reaction  appears  within  forty-eight  hours,  a  second  injection  is 
made  with  the  same  amount  of  tuberculin,  while  some  increase  it  to 
1  mg.  This  dose  is  again  increased  in  case  no  reaction  follows  to  5 
mg.  and  even  to  10  mg.  in  case  the  test  proves  negative  and  a  fourth 
injection  is  given.    Of  course,  in  children  smaller  doses  are  used. 

The  Reaction. — Usually  between  ten  to  twelve  hours,  rarely  between 
six  to  eight  hours,  in  case  the  reaction  is  positive,  constitutional, 
local,  and  focal  symptoms  make  their  appearance.  Some  say  that  it 
may  be  delayed  as  long  as  forty-eight  to  seventy-two  hours,  but  this 
must  be  very  rare;  I  have  never  encountered  it.  Of  the  constitutional 
symptoms,  fever  is  the  most  constant  and  reliable.  The  temperature 
begins  to  rise  six  to  twelve  hours  after  the  injection,  reaching  100°  to 
102°  F.,  and  in  those  showing  a  severe  reaction,  it  may  even  go  up  to 
104°  F.,  and  I  have  seen  several  cases  in  which  it  was  higher.  There 
are  usually  constitutional  symptoms  of  hyperthermia — ^headache, 
backache,  pains  in  the  joints,  weakness,  malaise  and,  in  some  cases, 
nausea  and  vomiting.  Rarely  the  prostration  is  very  pronounced, 
while  in  others  it  may  be  slight,  or  even  absent,  irrespective  of  the 
degree  of  fever.  These  symptoms  usually  subside  within  twenty-four 
to  forty-eight  hours  and  only  rarely  last  longer. 

At  the  site  of  the  injection  the  local  reaction  manifests  itself  in  ten- 
derness or  even  pain,  redness,  and  swelling,  which  may  be  small — only 
about  1  cm. — but  in  some  cases  the  infiltration  is  as  large  as  a  hen's 
egg.  Lymphangitis  and  enlargement  of  the  regional  lymphatic  glands 
may  occur. 

The  so-called  "focal  reaction"  is  very  rarely  observed  in  phthisis. 
It  is  said  to  consist  in  congestion  of  the  lesion  in  the  lung,  an  increase 
in  number  and  consonance  of  the  rales,  a  change  in  the  breath  sounds, 
and  extension  of  the  dull  areas,  accompanied  by  an  increase  in  the 
cough  and  expectoration.  Tubercle  bacilli  hitherto  absent  from  the 
sputum  may  now  be  found.  My  own  experience  leads  me  to  the  convic- 
tion that  this  focal  reaction  is  very  unreliable.  It  occurs  but  rarely, 
and  when  we  recall  that  in  phthisis  the  physical  signs  change  so  often, 
and  that  a  skilful  clinician  one  day  finds  signs  in  one  side  and  the  next 
day  in  another  without  tuberculin  injections,  we  may  always  suspect 
that  the  focal  reaction  is  not  necessarily  a  result  of  the  tuberculin 
injection,  at  least  its  inconstancy  should  lead  us  to  this  conclusion. 

Clinical  Value  of  the  Test. — The  object  of  the  test  is  to  clear  up  doubt- 
ful cases  in  which  there  are  symptoms  and  signs  pointing  to  active 
phthisis  but  which  are  not  con\'incing  to  clinch  the  diagnosis.  In  such 
cases,  the  advocates  of  the  test  claim  that  a  positive  reaction  decides 


INCIPIENT  PHTHISIS  323 

in  favor  of  active  disease,  while  a  negative  outcome  positively  excludes 
it.    It  lias  been  used  mostly  in  sanatoriums  for  these  purposes. 

Careful  analysis  of  the  conditions  under  which  this  test  is  negative 
or  positive  shows  that  it  is  hardly  of  greater  reliability  than  the  cuta- 
neous or  conjunctival  test.  Investigations  by  Franz/  Hamman  and 
Wolmann,^  Beck/  and  many  others  show  that  it  may  be  positive  in 
healthy  persons  who  do  not  develop  phthisis  subsequently.  The 
experience  of  all  who  have  applied  this  test  to  large  numbers  of  actually 
or  apparently  non- tuberculous  individuals  is  the  same  as  that  of  Franz, 
Hamman  and  Wolman,  Beck,  etc.  It  is  always  found  that  between  40 
and  60  per  cent,  of  humanity  react  to  the  subcutaneous  tuberculin 
test,  providing  it  is  repeated  with  ascending  doses  three  or  four  times. 

Specificity  of  the  Test. — ^^Ve  have  already  mentioned  that  many  non- 
tuberculous  substances  have  a  toxic  action  on  the  organism  infected 
with  tubercle  bacilli.  Thus,  according  to  experiments  by  Mettetal,^ 
Preisich  and  Heim,'^  Petruschky,''  and  many  others,  nucleins,  blood- 
serum,  testicular  extract  from  healthy  animals,  culture-free  bouillon, 
and  other  foreign  albumoses,  when  injected  into  tuberculous  persons, 
may  provoke  reactions  not  unlike  the  general  reaction  of  tuberculin. 
It  appears  that  the  tuberculin  reaction  is  part  and  parcel  of  the 
hypersensitiveness  of  the  infected  organism  to  foreign  proteins  of  any 
kind,  tuberculous  and  non- tuberculous  (see  p.  33). 

Diagnostic  Value. — Considering  that  the  subcutaneous  tuberculin 
test  discloses  latent  infection  as  well  as  active  tuberculous  disease, 
its  diagnostic  value  is  limited,  bearing  in  mind  that  over  90  per  cent, 
of  humanity  have  been  infected  at  some  period  of  their  life.  What  we 
look  for  is  active  disease  and  when  the  test  also  shows  those  who  are 
not  phthisical,  its  value  in  diagnosis  is  limited  indeed. 

"A  positive  tuberculin  reaction,"  say  Hamman  and  Wolman,  "is 
merely  confirmatory  evidence  and  never  decides  with  certainty  an 
otherwise  doubtful  diagnosis.  Indeed  we  feel  that  caution  is  decidedly 
in  place  not  to  lay  too  much  emphasis  upon  a  positive  reaction,  for  if 
a  patient  is  suffering  from  symptoms  which  may  be  accounted  for  by 
a  number  of  different  conditions,  and  by  applying  the  test  we  admit 
such  lyicertainty,  a  positive  reaction  does  not  impel  the  conclusion 
that  these  symptoms  are  due  to  tuberculosis.  If  such  a  large  percentage 
of  healthy  individuals  harbor  clinically  unimportant  tuberculous 
lesions,  a  certain  proportion  of  those  suspected  of  having  tuberculosis 
must  likewise  harbor  them,  though  the  symptoms  that  attract  our 
attention  may  be  due  to  some  other  disease."  With  this  view  the 
present  writer  agrees  entirely. 

1  Wien.  klin.  Wchnschr.,  1909,  xxii,  991. 
^  Tuberculin  in  Diagnosis  and  Treatment,  New  York,  1912. 
3  Deut.  med.  Wchnschr.,  1899,  xxv,  1.37. 

''  Valeur  de  la  tuberculine  dans  le  diagnostic  de  la  tuberculose  de  la  premiere  enfaiice, 
These  de  Paris,  1900. 
5  Zentralblatt  f.  Bakteriologie,  1902,  xxxi,  712. 
«Ergebu.  d.  Inn.  Med.  u.  Kinderheilk.,  1912,  ix,  557. 


324  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

Dangers  of  the  Test  and  Contra-indications. — The  subcutaneous 
tuberculin  test  is  not  without  dangers.  When  carelessly  performed 
with  excessive  doses,  latent  or  quiescent  lesions  may  be  flared  up  into 
activity.  Recently,  L.  Rabinowitsch,^  Bacmeister,-  Leo  Kessel,^  and 
others  have  shown  that  living  and  virulent  tubercle  bacilli  may  appear 
in  the  blood  after  an  injection  of  tuberculin.  In  some  cases  it  has  been 
observed  that  hemoptysis  is  provoked  by  the  test,  and  all  agree  that 
it  must  not  be  given  during  or  soon  after  a  pulmonary  hemorrhage. 
In  general  the  reaction  consists  essentially  in  a  transient  toxic  injury 
to  the  body,  and  the  nervous  system  bears  the  brunt  of  the  traumatism. 

It  has  also  been  found  dangerous  in  cases  of  heart  disease,  arterio- 
sclerosis, nephritis,  diabetes,  etc.  In  epileptics  it  has  been  observed 
that  the  reaction  may  provoke  convulsions.  Even  Bandelier  and 
Ropke  say  that  it  is  contra-indicated  when  miliary  tuberculosis  is 
suspected  "since  its  downward  course  might  be  accelerated."  Sahli,^ 
who  uses  tuberculin  for  therapeutic  purposes  extensively,  says:  "The 
use  of  tuberculin  for  diagnostic  purposes  ought  to  be  condemned.  It 
is  unreliable  both  positively  and  negatively.  Diagnostic  injections 
are  dangerous." 

The  Complement-fixation  Test. — Quite  recently  the  complement- 
fixation  test  on  the  lines  of  the  well-known  Wassermann  reaction  for 
syphilis  has  been  applied  in  the  diagnosis  of  tuberculosis.  It  has  been 
studied  by  Besredka  and  Manoukhine,"  Calmette  and  ^Nlassol,"^  Debains 
and  Jupille,  in  France,  and  in  England  by  James  Mcintosh,  Paul 
Fildes,^  J.  A.  D.  Radcliffe  and  Edward  Glover.^  In  this  country,  J. 
Bronfenbrenner,^°  A.  ]M.  Stimson,^^  Charles  F."  Craig,^-  and  others  have 
reported  good  results  with  this  test. 

But  so  far  the  results  appear  to  be  conflicting  in  certain  points,  so 
that  further  careful  research,  combined  with  clinical  observations  are 
necessary  before  deciding  on  the  speciflcity  and  clinical  applicability 
of  the  test  in  general  practice.  The  main  difficulty  is  evidently  the 
fact  that  difterent  authors  have  used  different  antigens.  Besredka 
used  one  prepared  from  egg-broth  cultures  of  tubercle  bacilli;  Rad- 
cliffe used  a  freshly  prepared  unsterilized  emulsion  in  saline  solution 
of  living  tubercle  bacilli  grown  on  glycerin-egg  medium;  Hammer 
used  an  alcoholic  extract  of  tuberculous  tissue  to  which  was  added  a 
certain  amount  of  old  tuberculin;    Stimson  and  Bronfenbrenner  use 

1  Berl.  klin.  Wchnschr.,  1913,  1. 

2  Munch,  med.  Wchnschr.,  191.3,  Ix. 
sAmer.  Jour.  Med.  Sci.,  1915,  cl,  3.37. 

^  Fifth  Confer.  Nat.  Assn.  Prev.  Consumption,  London,  1913,  p.  57. 

=  Ann.  de  I'lnst.  Pasteur,  1914,  xxviii,  569;  Compt.  rend.  Soc.  de  Biologie,  1914, 
\xxvi,  197. 

*  Ann.  de  i'lnst.  Pasteur,  1914,  xx\dii,  338. 

'  Compt.  rend.  Soc.  de  Biol.,  1914,  Ixxvi,  199. 

s  Lancet,  1914,  ii,  485. 

'Quarterly  .Jour,  of  Medicine,  1915,  viii,  339. 

'"  .^rch.  Intern.  Med.,  1914,  >iv,  786;    Proc.   Soc.  Exper.  Binl.  ami  Med.,  1914,  xii,  48. 
"  Bull.  101,  Hyg.  Laborat.,  U.  S.  P.  H.  S.,  1915. 
12  Amer.  Jour.  Med.  Sci.,  1915,  cl,  781. 


INCIPIENT  PHTHISIS  325 

Besredka's  antigen;  Craig's  antigen  consists  in  an  extract  of  several 
strains  of  human  tubercle  bacilli  prepared  by  a  special  method.  It 
is  thus  clear  that  with  so  man}^  different  methods,  the  results  are 
hardly  comparable.  Moreover,  as  Mcintosh  points  out,  Besredka's 
antigen  cannot  be  considered  absolutely  specific  since  Inman  and 
Kiiss,  and  Leredde  and  Rubinstein,  found  that  non-tuberculous 
syphilitics  gave  the  reaction  frequently.  Even  if  the  explanation  that  it 
is  due  to  the  lipoids  derived  from  the  egg  constituents  of  the  medium 
which  react  with  the  syphilitic  serum  in  a  manner  similar  to  tissue- 
extract  antigen,  is  correct,  it  does  not  help  us  in  our  efforts  to  find  a 
specific  test  for  active  tuberculosis. 

Various  authors  report  between  40  and  95  per  cent,  of  positive 
results  with  the  complement-fixation  test.  Some  state  that  a  positive 
reaction  means  an  active  tuberculous  process  somewhere  in  the  body. 
Mcintosh  and  Fildes  state  even  that  a  small  lesion  may  not  reveal 
itself  by  this  test;  "the  lesion  must  be  of  considerable  dimensions 
before  the  reaction  can  detect  it.  A  caseous  bronchial  gland  will  not 
give  a  positive  reaction;  indeed,  the  common  affection  of  the  cervical 
glands  will  usually  yield  a  negative  result.  On  the  whole,  we  have 
come  to  the  conclusion  that  a  lesion  in  order  to  give  positive  results 
must  be  of  such  dimensions  as  to  constitute  'disease'  and  require  the 
intervention  of  the  physician  or  surgeon.  We  look  upon  the  positive 
reaction,  therefore,  as  indicating  'active  tuberculosis.'  "  On  the  other 
hand,  Craig  found  that  65  per  cent,  of  clinically  inactive  cases  of  pul- 
monary tuberculosis  gave  positive  reactions.  Most  writers  obtained 
positive  reactions  in  patients  with  syphilis. 

The  test  deserves  further  trial  and  even  if  it  proves  that  it  has  the 
limitations  of  the  Wassermann  reaction  it  will  be  invaluable.  Mean- 
while some  important  points  are  to  be  borne  in  mind  while  interpreting 
the  findings.  Glover  shows  that  with  a  healed  lesion  "positive  fixa- 
tion may  occur  even  for  some  years  afterward  when  the  history  and 
symptomatology  do  not  point  to  a  progressive  lesion."  In  other 
words,  a  diagnosis  of  active  phthisis  should  not  be  made  in  the  absence 
of  symptoms  pointing  to  disease,  though  this  test  is  positive.  Mcintosh 
and  Fildes  also  state  that  "a  positive  result  indicates  tuberculosis 
with  certain  group  exceptions."  The  fact  that  nearly  all  syphilitics 
without  active  tuberculosis  give  positive  fixation  reactions,  has  already 
been  mentioned.  Another  fact  is  to  be  borne  in  mind:  Antitubercu- 
lin  is  not  constantly  present  in  the  sera  of  tuberculous  individuals, 
and  for  this  reason  the  reaction  is  at  times  negative  in  patients  with 
active  tuberculosis.  Indeed,  it  appears  that  in  the  later  stages  of 
phthisis  it  is,  as  a  rule,  negative;  experimental  evidence  is  in  agree- 
ment with  these  clinical  observations. 

Other  Special  Tests. — Most  of  the  other  special  diagnostic  tests 
which  have  been  brought  forward  from  time  to  time  have  been  found 
wanting  in  reliability ;  their  limitations  preclude  their  general  adop- 
tion.   Arneth's  blood-picture  has  never  been  considered  of  diagnostic 


326  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

value  and  was  only  urged  as  of  prognostic  significance  (see  p.  225). 
Wright's  opsonic-index  method  has  been  given  a  very  extensive  trial, 
especially  in  English-speaking  countries,  but  has  been  found  unreliable. 
The  results  are  very  conflicting  and  the  method  is  altogether  unsuit- 
able for  general  adoption. 

DIFFERENTIAL  DIAGNOSIS. 

Incipient  phthisical  lesions  are  to  be  differentiated  from  three 
groups  of  non-tuberculous  apical  lesions: 

1.  Collapse  induration. 

2.  Apical  catarrhs,  often  manifesting  themselves  after  attacks  of 
influenza,  or  found  in  persons  sufi^ering  from  pulmonary  emphysema, 
or  who  are  of  defective  muscular  development,  especially  women  and 
those  who  work  at  indoor  or  dusty  trades. 

3.  Apical  indurations  found  in  persons  with  heart  disease. 
Collapse  Induration  of  the  Apex. — The  two  apices  are  not  always 

symmetrical,  nor  do  they  always  have  the  same  resonance  and  breath 
sounds  in  apparently  healthy  people.  In  some,  the  dift'erences  are  so 
striking  as  to  attract  attention,  and  when  fever,  cough,  etc.,  occur  for 
any  reason,  a  diagnosis  of  phthisis  is  apt  to  be  made,  based  upon  these 
asymmetrical  findings  over  the  upper  parts  of  the  chest.  In  addition, 
there  is  quite  often  met  with,  collapse  of  the  apical  parenchyma,  resorp- 
tion of  the  air  with  subsequent  induration,  which  greatly  simulates 
a  phthisical  lesion.  Kronig^  first  described  these  cases  in  detail.  It 
is  a  purely  local,  non-infectious  lesion,  showing  impaired  resonance  or 
even  dulness,  rough  inspiratory  murmur,  harsh  or  prolonged  expira- 
tion and  even  true  bronchial  breathing  with  some  dry  crackling  over 
one  apex,  usually  the  right.  These  physical  signs  are  at  times  enough 
to  mislead  into  a  diagnosis  of  tuberculosis,  especially  if  the  patient 
states  that  he  had  some  blood-streaked  sputum,  which  may  happen 
during  an  acute  cold. 

The  points  of  differentiation  between  collapse  induration  and  phthisis 
are  the  following:  Patients  showing  signs  of  the  former  have  been 
sufferers  from  nasal  obstruction  since  childhood  and  generally  have 
enlarged  turbinated  bones,  nasal  polypi,  adenoids,  or  enlarged  tonsils. 
They  complain  that  they  have  not  been  able  to  breathe  properly 
through  the  nose  for  years,  have  expectorated  considerably,  sufiered 
from  dryness  and  itching  of  the  throat,  and  have  had  a  strong  tendency 
to  colds,  tonsillitis  and  frequent  bronchial  catarrh.  The  classical  face 
of  the  mouth-breather  is  often  seen  in  these  patients — open  mouth, 
enlarged  and  drooping  lips,  absence  of  the  nasolabial  fold,  etc.  In 
tuberculosis  all  these  are  usually  absent.  In  addition  to  the  absence 
of  tubercle  bacilli,  the  sputum  shows  distinct  evidences  that  it  is  derived 
from  the  upper  respiratory  tract:   It  is  watery,  mixed  with  saliva  and 

1  Deutsche  Klinik,  1907,  xi,  034. 


DIFFERENTIAL  DIAGNOSIS  327 

colorless;  sometimes  containing  gray  or  bluish  globules,  not  unlike  the 
kind  seen  in  pneumoko$iiosis.  Microscopically  there  are  often  found 
epithelial  cells  from  the  mouth,  nose  and  throat,  but  no  tubercle 
bacilli. 

The  physical  signs  may  exquisitely  simulate  those  of  phthisis.  The 
suggestion  of  Kronig  that  in  phthisis  the  base  of  the  affected  lung 
is  always  more  or  less  adherent  has  not  been  verified  by  the  writer. 
The  general  appearance  of  the  patient  is  rather  good.  In  spite  of  the 
fact  that  he  has  been  coughing  for  months  or  years,  he  is  well  nourished 
and  does  not  lose  weight,  as  is  usually  the  case  in  active  phthisis.  He 
is  able  to  keep  at  work,  and  the  sense  of  fatigue  and  languor  charac- 
teristic of  tuberculosis  is  lacking.  Moreover,  there  is  no  fever,  which 
can  be  discovered  in  every  case  of  active  phthisis.  Nor  is  there 
tachycardia  and  instability  of  the  pulse. 

Apical  Catarrh. — Most  of  us  have  been  warned  against  the  term 
apical  catarrh  of  a  non-tuberculous  nature  as  something  which  does 
not  exist  and  should  be  banished  from  medical  terminology.  But  it 
appears  that  during  recent  years  the  profession  is  again  acknowledg- 
ing that  there  is  often  to  be  seen  a  catarrhal  condition  of  one  or  both 
apices  which  is  not  caused  by  tubercle  bacilli.  Among  workers  at 
dusty  trades  it  is  quite  frequent,  especially  those  who  have  pulmonary 
emphysema.  After  attacks  of  influenza  there  is  very  often  left  a 
persisting  catarrh  of  one  or  both  apices.  In  persons  having  emphy- 
sematous lungs,  dulness  of  the  apices,  especially  the  right,  due  to 
local  bronchitis  and  tracheitis,  is  very  common.  The  difficulty  of 
differentiating  these  cases  from  phthisis  is  evident  when  we  men- 
tion that  in  our  hospital  work  we  quite  often  find  them  admitted  as 
advanced  consumptives,  and  only  after  observation  extending  over 
several  weeks  are  we  ready  to  discharge  them  as  non- tuberculous. 

They  are  distinguished  from  phthisis  by  the  absence  of  tubercle 
bacilli  from  the  sputum,  by  the  normal  temperature  and  pulse,  and  the 
blood- pressure  which  is  often  elevated  in  emphysematous  persons 
over  forty  years  of  age,  while  in  tuberculosis  it  is  low.  In  young 
persons  with  weak  muscles,  when  signs  of  apical  catarrh  are  encountered 
the  diagnosis  is  often  difficult  and  requires  prolonged  observation. 
The  absence  of  the  constitutional  symptoms  of  phthisis  points  to  their 
non-tuberculous  character. 

Pneumonic  Processes. — The  most  baffling  cases  which  simulate 
phthisis  to  a  degree  as  to  prove  perplexing  at  times  are  those  which 
are  caused  by  pulmonary  infection  with  various  cocci.  In  some 
only  observation  for  weeks  will  clear  up  the  case.  In  this  class  belong 
the  localized  catarrhs  of  the  apices  remaining  after  attacks  of  influenza, 
while  in  others  they  originate  primarily  after  some  exposure,  etc.  D. 
Finkler^  was  the  first  to  make  a  careful  study  of  these  streptococcus 
infections  of  the  lung;    Albert  Fraenkel^  also  describes  them,  and  in 

'  Infektion  der  Lunge  durch  Streptokokken  und  Influenzabazillen,  Bonn,  1895. 
2  Spezielle  Pathologic  und  Therapie  der  Lungekrankheiten,  Berlin,  1904,  p.  798. 


328  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

this  country  they  have  been  described  by  David  Riesman,'  WilHam 
Charles  White,-  and  the  present  writer.^  The  patients  cough,  expec- 
torate more  or  less  sputum,  have  fever;  at  times  the  temperature 
curve  is  not  unlike  that  common  in  incipient  phthisis,  and  there  may 
even  be  nightsweats,  anorexia,  and  loss  in  weight.  These  symptoms 
may  keep  on  for  several  weeks  or  even  two  or  three  months.  In 
many  cases  the  process  is  localized  in  one  of  the  lower  lobes  of  the 
lungs  and  manifests  itself  by  impaired  resonance,  bronchovesicular, 
and  at  times  pure  bronchial  breathing  over  a  limited  area,  and  rales, 
which  may  be  moist  and  consonating.  After  a  protracted  illness  the 
patient  invariably  recovers  and  all  the  local  signs  disappear. 

In  the  cases  in  which  the  lesion  is  in  a  lower  lobe,  the  diagnosis 
should  not  be  difficult.  It  must  never  be  lost  sight  of  that  initial  tuber- 
culous lesions  are  almost  invariably  localized  in  the  upper  lobes  of  the 
lungs,  and  it  requires  great  courage  on  the  part  of  a  physician  to 
diagnosticate  tuberculosis  with  an  initial  lesion  in  a  lower  lobe,  unless 
there  is  positive  sputum.  This  is  a  point  which  cannot  be  emphasized 
too  strongly.  In  these  pneumonic  processes,  the  sputum  lacks  both 
tubercle  bacilli  and  elastic  fibers. 

Greater  difficulties  are  presented  when  these  pneumonic  processes 
are  localized  in  one  of  the  pulmonary  apices ;  at  times  only  prolonged 
observation  clears  up  the  case.  Such  cases  have  been  reported  by 
Kiilbs,*  Friederich  jNIiiller,  White,  and  others.  I  see  them  very  often 
in  New  York  City  treated  at  the  tuberculosis  clinics,  and  have  known 
of  some  who  have  been  banished  to  sanatoriums  or  distant  climates. 
They  usually  occur  in  persons  who  have  been  emphysematous,  espe- 
cially such  as  have  been  mouth-breathers,  or  have  had  bronchitis,  or 
tracheitis  for  many  years.  The  only  criteria  for  diagnosis  which  have 
helped  me  are  the  following:  The  sputum  is  negative  as  regards 
tubercle  bacilli  and  elastic  tissue;  the  fever  which  is  observed  the 
first  week  or  two  after  the  onset  of  the  cough  disappears  soon,  and 
nightsweats  are  very  rare.  The  appetite  of  the  patient  is  usually  good 
and,  inasmuch  as  he  is  frightened  by  being  classed  as  a  "suspect," 
he  soon  begins  to  take  care  of  himself  and  eats  well,  so  that  he  gains 
in  weight.  But  what  is  of  most  importance  is  that  the  rapid  pulse 
of  incipient  phthisis  is  lacking.  We  have  already  stated  that  tuber- 
culosis without  tachycardia,  or  at  least  instability  of  the  pulse,  is 
exceedingly  rare.  In  short,  a  diagnosis  can  be  made  by  careful  clinical 
observation  of  the  constitutional  symptoms  for  a  few  weeks. 

William  Charles  White  recently  reported  a  case  of  diphtheria  of  the 
lung  which  exquisitely  simulated  incipient  phthisis. 

Apical  Induration  with  Cardiac  Disease. — Persons  suft'ering  from  heart 
disease,  especially  mitral  stenosis,  often  cough,  spit  blood,  have  mild 

lAmer.  Jour.  Med.  Sci.,  1913,  cxlvi,  313. 

2  Trans.  Nat.  Assn.  Study  and  Prev.  Tuberc,  1915,  xi,  140. 

2  Nontuberculous  Apical  Lesions,  New  York  Med.  Jour.,  1913,  xcviii,  13. 

^Ztschr.  f.  klin.  Medizin.,  1912,  Ixxiii,  169. 


DIFFERENTIAL  DIAGNOSIS  329 

fever  and  emaciation,  and  are  often  treated  for  tuberculosis.  We  have 
already  mentioned  that  next  to  tuberculosis,  mitral  stenosis  is  a  fre- 
quent cause  of  hemoptysis  (see  p.  196).  When  the  lungs  are  carefully 
examined,  it  may  be  found  that,  because  of  the  degeneration  of  the 
cardiac  muscle,  there  is  produced  a  passive  congestion  or  even  indura- 
tion of  one  or  both  apices.  In  some  the  clinical  picture  simulates  that 
of  phthisis  to  a  remarkable  degree. 

Mistakes  of  this  character  can  be  avoided  by  carefully  examining 
the  heart  in  every  case  and,  while  it  is  possible  that  patients  with 
mitral  stenosis  should  become  tuberculous,  yet  this  is  very  rare.  In 
fact,  it  has  been  my  rule  never  to  diagnosticate  tuberculosis  in  one 
showing  disease  of  the  mitral  valve  unless  the  sputum  reveals  tubercle 
bacilli,  or  finding  signs  of  pulmonary  excavation  on  physical  examina- 
tion. Mitral  disease  is  almost  always  accompanied  by  cardiac  hyper- 
trophy, which  is  never  seen  in  phthisis. 

Chronic  Bronchitis  and  Bronchiectasis. — In  these  conditions  the 
changes  in  breath  sounds  and  the  rales  are  distributed  all  over  the  chest, 
especially  the  low^er  parts,  and  are  only  rarely  localized  at  the  upper 
parts  of  the  thorax,  when  they  may  be  mistaken  for  phthisis.  The 
abundant  sputum  separates  into  three  layers,  contains  no  tubercle 
bacilli,  and  the  general  condition  of  the  patient  is  rather  good,  while 
with  tuberculosis  of  such  extensive  distribution,  there  would  be  fever, 
emaciation,  etc.  Bronchiectasis  is  occasionally  very  difficult  to  diflfer- 
entiate  from  phthisis  when  hemoptysis  occurs.  In  many  cases  we 
must  wait  till  the  hemorrhage  ceases  for  a  careful  examination  which 
shows  that  in  bronchiectasis  the  lesion  is  located,  as  a  rule,  in  the  lower 
parts  of  the  lungs  and  not  in  the  apex;  the  sputum  contains  no  tubercle 
bacilli  nor  elastic  tissue,  which  is  never  absent  in  phthisis,  and  the 
history  of  the  case  shows  that  the  patient  has  coughed  and  expecto- 
rated for  many  years,  perhaps  since  childhood,  yet  his  general  con- 
dition is  fair  or  even  good.  On  the  other  hand,  in  phthisis  the  active 
symptoms  of  disease  begin  later  in  life,  and  wdth  extensive  lesions 
there  is  emaciation,  debility,  and  especially  tachycardia. 

More  difficult  is  it  to  diagnosticate  phthisis  implanted  in  a  chest  with 
chronic  bronchitis  or  pulmonary  emphysema.  In  some  cases  only 
the  clinical  course — the  emaciation,  the  fever,  nightsw^eats,  etc. — and 
particularly  the  bacteriological  findings  decide. 

Syphilis  of  the  Lung. — This  often  exquisitely  simulates  phthisis.  It 
is,  however,  a  very  rare  disease.  Osier  found  only  12  cases  of  syphilis 
of  the  lung  in  2800  postmortems  at  the  Johns  Hopkins  Hospital.  In 
8  of  these  the  lesions  were  in  congenital  syphilis.  In  11  cases  there 
were  definite  gummata.  Clinically  the  presence  of  syphilis  of  the 
lung  was  suspected  in  only  3  of  the  cases.  When  it  occurs,  it  may  be 
distinguished  from  phthisis  by  the  fact  that  in  the  former  the  lesion 
is  usually  at  the  base,  the  Wassermann  reaction  and  the  absence  of 
tubercle  bacilli  from  the  sputum.  In  some  the  therapeutic  test  alone 
decides. 


330  CHRONIC  PHTHISIS— INCIPIENT  STAGE 

These  two  diseases  occur  very  often  together,  and  it  appears  that 
syphihs  modifies  the  course  of  phthisis  rather  favorably,  probably 
because  it  is  characterized  by  the  tendency  to  the  formation  of  con- 
nective tissue.  It  should  always  be  remembered  that  the  presence  of 
syphilis  does  not  exclude  phthisis,  but  that  the  latter  is  very  often 
engrafted  on  the  former. 

Duration  of  the  Incipient  Stage. — Incipient  phthisis  is  also  called 
"early"  phthisis,  and  thus  a  confusion  is  caused  in  the  minds  of  the 
laity,  as  well  as  of  physicians  who  assume  that  a  case  is  incipient  only 
for  a  certain  time  and  then  progresses  to  the  second  or  third  stage, 
unless  properly  treated.  This  is  wrong.  There  are  cases  which  are 
"advanced"  soon  after  the  active  symptoms  manifest  themselves, 
while  others,  though  remaining  active  for  years,  never  pass  beyond 
the  stage  of  incipiency.  Indeed,  we  meet  with  many  patients  who 
have  been  tuberculous  for  many  years,  and  have  been  admitted  to 
sanatoriums  several  times  as  "early"  cases. 

The  sagacious  clinician,  Laennec,  stated  nearly  one  hundred  years 
ago  that  it  appears  to  him  that  hardly  any  consumptive  succumbs  to 
the  first  attack  of  the  disease,  and  that  in  the  vast  majority  of  cases 
the  first  attack  is  erroneously  diagnosticated  as  a  mild  respiratory 
trouble.  The  disease  then  remains  latent  for  a  longer  or  shorter  time 
to  break  out  again,  perhaps  with  greater  severity.  Many  years  of 
research  along  scientific  lines  have  confirmed  Laennec's  observation. 
A  large  number  of  cases  never  become  "advanced"  in  the  sense  we  use 
this  term.  Others  show  greater  activity,  and  the  process  in  the  lungs 
proceeds  from  infiltration  to  caseation,  softening  and  excavation  within 
six  months  or  a  year.  A  larger  proportion  of  active  cases  remain 
quiescent  for  one  or  two  years,  and  then  suddenly  take  a  turn  for  the 
worse  and  the  patient  sinks,  succumbing  to  exhaustion  or  to  some 
complication. 

On  the  whole  it  may  be  stated  that  "incipiency"  does  not  necessarily 
imply  earliness  of  the  process.  It  means  a  limited  and  circumscribed 
lesion  which  is  not  manifesting  a  tendency  to  acute  progression,  but 
either  remains  quiescent  or  leans  to  cicatrization  of  the  lesion.  In 
this  stage  the  patient  may  remain  for  many  years,  and  no  average 
duration  can  be  assigned.  It  can  only  be  estimated  in  the  individual 
patient,  depending  as  it  does  on  so  many  different  and  complex  factors 
which  have  been  discussed  elsewhere  in  this  book. 


CHAPTER  XX. 
CHRONIC  PHTHISIS.      ADVANCED  STAGES. 

Course  of  Incipient  Phthisis. — In  a  large  proportion  of  cases  phthisis 
does  not  pass  beyond  the  stage  of  incipiency.  The  patient  coughs, 
expectorates,  has  fever,  hemoptysis,  etc.,  for  several  weeks  or  months, 
and,  after  taking  a  rest  in  the  country,  spending  a  few  months  in  a 
sanatorium,  or  even  while  continuing  at  his  occupation,  he  slowly 
recuperates  and  recovers,  never  to  be  troubled  again  with  pulmonary 
symptoms.  In  most  of  these  cases  there  are  left  remnants  of  the  pul- 
monary lesion  in  an  apex,  manifesting  themselves  in  the  shape  of 
impaired  resonance,  some  prolonged  expiration  and  sibilation.  This 
conforms  to  the  abortive  type  of  tuberculosis  which  will  be  discussed 
later  on  (Chapter  XXIII). 

But  in  many  cases  the  disease  progresses  steadily,  especially  when 
no  proper  treatment  has  been  instituted,  and  occasionally  irrespective 
of  the  treatment.  In  a  small  proportion  of  cases  the  progress  is  rather 
rapid  and  within  one  or  two  months  after  the  first  symptoms  have 
appeared  the  patient  is  a  confirmed  consumptive;  while  in  others  the 
course  is  slower,  the  patient  keeps  on  coughing,  expectorating,  losing 
flesh  and  strength  for  several  months  or  years,  when  a  change  takes 
place  and  he  is  apparently  improved  or  cured,  or  he  succumbs  to  the 
disease. 

In  the  vast  majority  the  progress  of  the  disease  is  marked  by  dis- 
tinct remissions,  during  which  the  patient  feels  comparatively  well, 
is  able  to  pursue  his  vocation,  and  he,  as  well  as  his  physician,  are 
under  the  impression  that  a  permanent  cure  has  been  attained,  to  be 
undeceived  now  and  then  by  the  appearance  of  an  acute  exacerbation 
of  the  disease  during  which  the  patient  is  laid  up  for  several  days  or 
weeks,  or  by  a  pulmonary  hemorrhage  which  may  or  may  not  be 
copious;  an  attack  of  pleurisy,  with  or  without  effusion,  etc. 

There  is  another  class  of  cases  in  which  the  focus  in  the  lung  remains 
quiescent,  but  does  not  cicatrize  for  many  years.  Physical  examina- 
tion of  the  chest  shows  distinct  signs  of  an  active  pulmonary  lesion 
and  an  examination  of  the  sputum  may  even  disclose  tubercle  bacilli, 
but  the  symptomatology  and  course  are  benign — the  cough  is  mild, 
there  is  no  fever,  no  nightsweats,  no  emaciation,  and  the  patient  is 
capable  of  working  at  his  vocation  for  years. 

Oscillating  Course  of  Chronic  Phthisis. — A  continuous  course  from 
bad  to  worse  till  the  patient  dies,  or  with  improvement  till  he 
recovers,  is  uncommon   in  chronic  phthisis.     It  is  characteristic  of 


332  CHRONIC  PHTHISIS— ADVANCED  STAGES 

either  the  abortive  form  of  phthisis,  on  the  one  hand,  or  of  acute  gal- 
loping phthisis,  on  the  other.  But  the  usual  case  of  chronic  phthisis 
pursues  a  discontinuous,  paroxysmal,  I  maj^  say  a  capricious  course, 
marked  by  periods  of  acute  or  subacute  exacerbations  of  the  sj'mptoms, 
and  periods  of  remissions  during  which  the  patient  is  more  or  less  free 
from  the  troublesome  symptoms,  or  he  may  even  feel'  comparatively 
well,  working  efficiently,  especially  if  he  is  engaged  in  some  intellectual 
pursuit.  I  have  seen  many  who  have  worked  at  hard  manual  labor 
for  months  until  an  acute  exacerbation  laid  them  up  for  several  weeks, 
but  they  sooner  or  later  recuperated  and  went  to  work  again  until 
another  acute  exacerbation  interfered. 

These  acute  exacerbations  during  the  course  of  chronic  phthisis 
usually  have  morbid  anatomical  substrata.  In  active  phthisis  the 
affected  part  of  the  lung  caseates,  softens  and  is  finally  eliminated  by 
cough  and  expectoration,  leaving  a  fistula  to  drain  the  excavation, 
surrounded  by  a  fibrous  capsule  which  inhibits  or  prevents  absorption 
of  toxic  matter.  The  patient  may  feel  comparatively  w^ell  as  long  as 
the  cavity  in  the  lung  is  well  drained.  But  now  and  then  the  fistula 
is  obstructed,  or  a  new  area  becomes  involved  by  contiguity  or  metas- 
tasis, and  again  acute  symptoms  of  constitutional  toxemia  make  their 
appearance.  This  acute  exacerbation  keeps  on  for  some  time  till  either 
the  fistula  opens  again,  or  the  newly  involved  area  has  softened  and 
the  products  of  tissue  disintegration  are  eliminated  and  the  patient 
feels  well  again,  though  he  is  by  no  means  cured. 

This  undulating  course  of  phthisis  can  be  clearly  observed  by 
studying  the  temperature,  expectoration,  emaciation,  etc.,  of  the 
patient,  as  was  done  by  Bezan^on,^  Serbonnes^  and  others.  It  may 
keep  on  for  many  years.  In  most  cases  one  of  two  things  finally  occurs 
— either  the  infiltrated  or  excavated  area  in  the  lung  cicatrizes  or 
becomes  encapsulated  and  shrinks  and  the  disease  is  arrested;  or 
during  one  of  these  exacerbations  the  pulmonary  involvement  becomes 
too  extensive  and  can  no  more  become  quiescent  and,  with  or  without 
some  complication,  the  patient  succumbs. 

We  may  say  that  during  the  long  course  of  chronic  phthisis  there  is 
an  intense  struggle  between  the  bacilli  and  the  resistance  of  the  host. 
We  have  seen  that  everybody  possesses  more  or  less  resistance;  else 
every  infection  would  speedily  prove  fatal.  In  this  struggle  the  bacilli 
gain  the  upper  hand  for  a  time  and  cause  an  acute  exacerbation,  but 
the  innate  resistance  is  again  called  upon  and  usually  responds,  the 
result  being  a  truce,  until  the  bacilli  again  catch  the  organism  napping. 
The  final  outcome  depends  on  many  and  complex  factors  which  are 
discussed  elsewhere. 

Symptoms. — The  cough,  which  may  have  been  mild  during  the 
incipient  stage,  gradually  becomes  more  and  more  annoying  and 
productive.    It  may  be  painful,  paroxysmal  and  exhausting,  and  end 

1  Paris  Medical,  1911,  p.  133. 

2  Les  Poussees  evolutives  de  la  tuberculose  pulmonaire  chroiiiquc,  Paris,  1910. 


SYMPTOMS  333 

in  vomiting,  especially  after  the  evening  meal.  But  with  the  advance 
of  the  process  the  cough  is  ameliorated  in  most  cases;  while  it  does 
not  cease  altogether,  it  becomes  "looser;"  the  sputum  is  brought  up 
without  great  effort.  During  acute  exacerbations  it  is  usually  aggra- 
vated, often  painful  due  to  complicating  pleurisy,  etc.  In  some  cases 
the  cough  is  mild  throughout  the  course  of  the  disease,  while  in  others 
it  constitutes  the  main  complaint  of  the  patient.  In  fatal  cases  it 
may  be  absent  during  the  last  few  days  of  life,  when  the  reflexes  are 
abolished,  or  because  of  severe  emaciation  and  muscular  atrophy, 
the  patient  has  not  enough  strength  for  the  efforts  at  coughing. 

The  mucoid  sputum  of  the  incipient  stage  becomes  more  and  more 
mucopurulent  with  the  advance  of  the  disease  and  almost  invariably 
contains  tubercle  bacilli.  Exceptionally,  none  are  found  in  a  case 
that  keeps  on  progressing,  even  to  fatal  issue.  Elastic  fibers  are, 
however,  found  in  practically  all  cases  in  which  the  disease  has  passed 
incipienc}',  owing  to  the  destruction  of  lung  tissue  during  caseation 
and  liquefaction.  Immediately  before  and  during  an  acute  exacerba- 
tion the  amount  of  sputum  may  be  diminished,  but  within  a  few  days 
it  again  increases  in  quantity.  With  the  disintegration  of  lung  tissue 
and  formation  of  vomicae,  the  character  of  the  sputum  changes;  it 
becomes  thick,  nummular  and  sinks  in  the  water  of  the  receiving  vessel. 
During  hemorrhages  it  is  sanguineous,  and  often  without  any  evident 
hemorrhage  it  is  tinged  with  blood.  During  quiescent  periods  the 
amount  expectorated  is,  as  a  rule,  diminished;  it  may  lose  its  purulent 
character  and,  when  a  cure  is  established,  the  expectoration  may 
cease.  In  fatal  cases  we  often  note  that  during  the  last  few  days  little 
sputum  is  brought  up.  The  patient  has  not  sufficient  strength  to 
expel  it. 

The  temperature  in  active  advanced  cases  is  not  of  a  characteristic 
type.  In  progressive  cases  it  may  be  continuous  or  remittent  till 
the  end — recovery  or  death.  Usually  the  curve,  when  studied  for 
several  months  continuously,  pursues  an  undulating  or  cyclic  course. 
For  several  weeks  it  is  high,  no  matter  what  type  it  is,  rising  to  101° 
or  even  104°  F.  in  the  afternoon,  and  declining  several  degrees  in  the 
morning,  in  many  cases  even  to  a  subnormal  degree.  Slowly  an 
improvement  is  noted,  the  temperature  becomes  lower  and  lower  and 
we  may  find  a  period  of  either  subfebrile  or  even  normal  temperature 
for  a  few  weeks.  In  many  cases  I  have  noted  a  subnormal  tempera- 
ture for  comparatively  long  periods. 

But  suddenly — perhaps  after  a  chill  or  some  indiscretion — or  grad- 
ually, the  temperature  rises  again  and  keeps  at  a  high  level  for  several 
days  or  weeks,  thus  marking  an  extension  of  the  process  to  a  hitherto 
unaffected  area  of  the  lung,  or  some  complication. 

It  is  noteworthy  that  during  the  afebrile  periods  the  patient  feels 
quite  well  and  for  weeks  may  consider  himself  cured,  to  be  sadly  dis- 
appointed during  the  acute  exacerbations  which  are  sure  to  come  in 
most  cases.     Even  during  febrile  periods  many  feel  comparatively 


334 


CHRONIC  PHTHISIS— ADVANCED  STAGES 


well  and  have  a  good  or  fair  appetite  as  was  already  stated.  The 
intellect  is  usually  clear;  those  engaged  in  intellectual  pursuits  may 
follow  their  vocations  during  the  exacerbations.  I  have  had  patients 
who  did  business  on  a  high  scale  under  such  circumstances,  and  writers 
and  artists  who  produced  their  best  work  while  the  thermometer 
registered  103°  F.  The  euphoria,  which  is  characteristic  of  phthisis, 
is  best  observed  in  far-advanced  cases. 

Emaciation  goes  hand-in-hand  with  other  constitutional  symptoms, 
especially  fever.  Those  who  have  no  quiescent  periods  lose  flesh  very 
rapidly  and  within  a  few  months  may  be  reduced  to  mere  skeletons. 
In  those  in  whom  the  disease  runs  an  undulating  course,  we  often 


Fig.  66. — The  phthisical  or  flat  chest.     Habitus  phthisicus. 


note  a  gain  in  weight  during  afebrile  periods,  and  if  the  fever  is  mild 
during  acute  exacerbations  and  of  short  duration,  the  loss  in  weight 
may  be  insignificant.  They  may  be  ahead  in  this  regard  at  the  end 
of  a  year  or  two,  although  the  process  in  the  lungs  remains  stationary 
or  has  even  progressed. 

Toward  the  end  the  emaciation  is  very  pronounced  and  deserves 
the  name  consumption.  Then  it  is  not  only  the  fever,  cough  and 
expectoration  that  arc  exhausting  the  patient,  but  also  the  lack  of 
nourishment  owing  to  anorexia,  diarrhea,  and  perliaps  dysphagia  when 
the  larynx  is  implicated.  The  preservation  of  the  botly  weight,  which 
is  very  frequent  in  fibroid  phthisis,  is  only  rarely  seen  in  chronic 


PHYSICAL  SIGNS  335 

phthisis,  and  when  found  it  is  an  indication  of  improvement,  or  that 
the  quiescent  periods  are  of  long  duration. 

Hemoptysis  is  comparatively  infrequent  during  this  period,  except- 
ing in  very  advanced  cases  with  cavities,  when  a  terminal  hemorrhage 
may  carry  off  the  patient,  and  in  those  suffering  from  hemorrhagic 
phthisis  (see  p.  192)  it  may  recurr  at  irregular  intervals.  As  was 
already  stated,  most  of  the  hemorrhages  at  this  period,  even  when 
profuse,  end  in  recovery. 

The  other  symptoms  of  chronic  phthisis  have  already  been  described 
in  detail  in  previous  chapters. 

Physical  Signs. — Depending  on  alterations  in  the  pulmonary 
parenchyma,  pleura,  mediastinum  and  chest  walls,  the  physical  signs 
of  advanced  phthisis  are  complex.  By  percussion  and  auscultation 
we  may  determine  with  a  reasonable  degree  of  certainty  the  nature 
of  the  lesion,  as  well  as  the  condition  of  the  apparently  unaffected 
parts  of  the  thoracic  viscera.  But  with  the  progress  of  the  disease, 
the  changes  found  on  physical  exploration  become  more  and  more 
variegated  and,  owing  to  frequent  overlapping  of  pathological  changes, 
their  complexity  is  so  great  that  it  is  often  quite  difBcult  or  impossible 
to  determine  exactly  the  details  of  these  changes  by  physical  examina- 
tion. This  is  well  illustrated  by  the  difficulty  of  differentiating  pleural 
adhesions  before  inducing  a  therapeutic  pneumothorax,  and  by  the 
number  of  cavities  that  are  missed  during  life  and  found  at  necropsy. 
Radiography  is  of  immense  value  at  this  stage,  but  it  is  not  infallible, 
as  has  already  been  shown. 

Percussion. — The  tuberculous  infiltration  usually  extends  in  hori- 
zontal planes,  though  frequently  metastatic  deposits  of  tubercle 
are  found  at  a  distance  from  the  original  focus  in  the  same  or  the 
opposite  lung.  The  result  is  that  the  impairment  of  resonance  found 
over  one  apex  during  the  incipient  stage  extends  mainly  downward, 
and,  in  progressive  cases,  we  soon  find  dulness  as  far  as  the  third  or 
fourth  rib  or  lower.  The  pitch  of  the  note  depends  on  the  density 
of  the  infiltration,  on  the  presence  or  absence  of  excavations  and  on 
the  condition  of  the  pleura.  On  the  unaffected  side  a  hyperresonant 
note  may  be  elicited,  which  may  be  accentuated  by  vicarious 
emphysema. 

Dulness  is  very  frequently  found  in  the  interscapular  spaces  which 
may  be  an  expression  of  enlarged  peribronchial  glands,  or  infiltration 
of  the  apex  of  the  lower  lobe  of  the  lung.  In  the  majority  of  cases 
there  is  more  or  less  retraction  of  the  base  of  the  lung,  easily  made 
out  by  tidal  percussion. 

With  percussion  we  may  also  determine  the  position  of  the  heart 
which  in  many  cases  is  of  immense  diagnostic  significance,  as  has 
been  pointed  out  elsewhere  by  the  writer. "^  In  phthisis  the  heart  is, 
as  a  rule,  dislocated  toward  the  affected  side,  the  reverse  of  conditions 

1  Arch,  of  Intern.  Med.,  1914,  xiii,  G56. 


336  CHRONIC  PHTHISIS— ADVANCED  STAGES 

found  in  pleural  effusions,  pneumothorax,  etc.  It  is  therefore  impor- 
tant to  determine  the  position  of  the  heart  in  cases  showing  intense 
dulness  of  the  lower  parts  of  the  chest  on  one  side  when  the  problem 
arises  whether  it  is  due  to  an  effusion,  or  to  thickened  pleura  with 
pulmonary  retraction.  Exploratory  puncture,  if  negative,  is  not  con- 
clusive, but  when  we  find  the  heart  displaced  to  the  opposite  side, 
we  may  conclude  that  there  is  an  effusion,  while  when  it  is  dislo- 
cated toward  the  affected  side,  it  is  due  to  excavation  and  to  pleural 
thickening. 

The  routine  methods  of  physical  exploration  show  the  location 
of  the  heart  in  phthisis  easily  and  vividly;  but  in  many  cases  the 
diagnosis  is  difficult,  and  occasionally  almost  impossible.  The  side 
of  the  heart  adjoining  the  healthy  lung  is  easily  made  out  by  percus- 
sion, but  the  cardiac  dulness  at  the  side  adjoining  the  affected  lung 
merges  with  the  dulness  of  the  infiltrated  and  consolidated  lung  tissue 
or  thickened  pleura,  and  it  is  difficult  to  separate  by  any  method  of 
percussion.  The  fluoroscope  and  the  skiagraphic  plate  also  fail  at 
times  to  show^  a  definite  outline  of  the  borders  between  the  heart 
and  lung.  Indeed,  I  have  found  at  times  that  orthodiagraphy  was  of 
no  avail. 

Dextrocardia  is  not  rare  in  extensive  right-sided  lesions.  It  is  to 
be  differentiated  from  complete  transposition  of  the  viscera  by  the 
location  of  the  liver,  spleen,  etc. 

Auscultation. — Auscultation  in  advanced  phthisis  is  of  even  greater 
diagnostic  significance  than  percussion  and  skiagraphy,  because  it 
shows  distinctly  the  progress  of  the  process  in  the  lungs,  especially 
its  activity.  The  diagnosis  of  a  healed  lesion  can  only  be  made  by  a 
study  of  the  constitutional  symptoms  and  a  careful  consideration  of 
the  auscultatory  phenomena  elicited  over  the  chest. 

The  breath  sounds  which,  during  the  incipient  stage,  may  have  been 
somewhat  altered,  rough,  cog-wheel  or  feeble,  now  become  more  and 
more  bronchial  or  tubular  in  character.  Excepting  in  very  acute  cases, 
which  do  not  concern  us  here,  bronchial  breathing  does  not  appear 
suddenly  in  chronic  phthisis.  Following  a  progressive  case  we  may 
observe  that  the  cog-wheel  breathing  changes  by  degrees;  first  the 
expiratory  murmur  becomes  prolonged,  then  the  sounds  assume  a 
bronchovesicular  character,  indicating  that  the  breath  sounds  are 
mixed,  the  vesicular  coming  from  the  healthy  lung,  and  the  bronchial 
from  the  disseminated  infiltrated  patches.  When  these  patches  con- 
glomerate and  the  part  of  the  lung  consolidates  into  an  extensive 
airless  area,  thus  acting  as  a  good  conductor  of  the  tracheobronchial 
murmur  to  the  surface,  we  get  bronchial  breathing.  With  the  onset 
of  softening  the  products  of  tissue  disintegration  are  expelled,  leaving 
an  excavation  and  we  often,  though  not  invariably,  hear  cavernous 
or  amphoric  breathing,  which  will  be  discussed  later  on. 

The  advance  of  the  lesion  is  characterized  pathologically  by  soften- 
ing of  lung  tissue,  followed  by  liquefaction  and  cavity  formation. 


CAVITIES  337 

These  changes  are  best  determined  by  auscultation  and  the  detection 
of  moist  rales  which  are  produced  by  the  air  current  passing  from 
the  bronchi  into  the  diseased  area  filled  with  debris  of  disintegrated 
tissue.  These  rales  are  of  various  sizes — large,  medium  or  small — 
according  to  the  size  of  the  bronchus  or  excavation  in  which  they  are 
produced.  Usually  they  are  consonating,  ringing  and  either  provoked 
or  intensified  by  cough.  Their  diagnostic  significance  lies  mostly 
in  their  localization  and  persistence.  They  are  mostly  found  over 
the  supraspinous  fossse,  in  the  upper  part  of  the  interscapular  space 
and  especially  above  and  below  the  clavicle  and  with  them  we  usually 
hear  low-pitched,  bronchial  breathing.  When  heard  unilaterally  and 
persistently  in  any  of  these  locations,  they  are,  with  but  few  exceptions, 
pathognomonic. 

The  onset  of  softening  is  characterized  by  the  appearance  of  moist 
rales,  usually  small  or  of  medium  size.  They  have  been  called  by  the 
French  rales  de  friture  because  they  simulate  the  sounds  heard  when 
frying  something.  But  we  must  guard  against  overestimating  the 
extent  of  the  disease  by  wide  distribution  of  rales.  With  concomitant 
bronchitis  they  may  be  distributed  all  over  the  chest  or  all  over  one 
hemithorax,  while  the  tuberculous  lesion  is  rather  limited.  After 
pulmonary  hemorrhages  the  rales  are  heard  far  away  from  the  tuber- 
culous area  and  we  must  be  guarded  in  concluding  that  it  is  an 
indication  of  wide-spread  extension  of  the  tuberculous  lesion.  The 
thermometer  is  a  better  guide  under  such  circumstances. 

On  the  whole,  it  can  be  stated  that  the  activity  of  the  tuberculous 
process  may  be  gauged  by  the  number,  character  and  distribution  of 
moist  rales  audible  over  the  chest.  The  larger  their  number,  the 
larger  their  consonance,  when  localized  over  a  limited  area,  the  more 
active  the  process,  while  absence  of  rales,  coupled  with  absence  of 
constitutional  symptoms,  indicates  an  arrest  in  the  progress  of  the 
disease. 

Sibilation  is  quite  frequently  heard  in  cases  of  advanced  phthisis 
and  it  may  be  caused  by  various  conditions.  In  the  interscapular 
spaces  and  near  the  two  sides  of  the  sternum  whistling  sounds  are 
an  indication  of  tracheobronchial  adenopathy  with  pressure  on  the 
bronchi.  In  some  cases,  we  hear  sonorous  rales  all  over  the  chest  or 
unilaterally  in  cases  complicating  bronchitis  or  emphysema;  over 
areas  of  localized  vicarious  emphysema,  sibilation  is  also  heard  at 
times.  For  a  long  time  or  permanently,  after  a  lesion  has  healed, 
there  may  remain  sibilation,  "cicatricial  rales." 

Friction  sounds  are  very  frequently  heard.  Their  significance  has 
already  been  discussed. 

Cavities. — This  stage  is  characterized  by  the  formation  of  pulmonary 
excavations.  The  constitutional  symptoms  accompanying  the  forma- 
tion of  cavities  depend  on  the  acuteness  of  the  process.  As  long  as 
the  excavation  is  surrounded  by  infiltrated  and  caseated  lung  tissue, 
the  symptoms  are  acute — high  fever  of  a  continuous  or  remittent 
22 


338  CHRONIC  PHTHISIS— ADVANCED  STAGES 

type,  profuse  nightsweats,  severe  cough  with  abundant  expectoration, 
rapidly  progressing  emaciation,  etc.  But  in  most  cases  the  process 
is  not  so  acute.  The  excavation  is  surrounded  by  a  fibrous  shell  which 
limits  its  progress  and  prevents  absorption  of  the  toxic  products  to 
a  great  extent,  so  that  the  patient  may  feel  quite  well  despite  the 
formation  of  more  or  less  extensive  excavations  in  his  lungs.  In  the 
chronic  cases  that  do  not  succumb,  but  do  not  heal  either,  the  cavity 
may  keep  on  secreting  mucopurulent  matter  which  is  promptly 
removed  through  the  fistulous  tract  that  leads  to  a  bronchus. 

It  is  in  these  chronic  cavitary  cases  that  we  meet  with  the  undulating 
clinical  picture  of  phthisis  described  above.  Whenever  the  fistulous 
tract  leading  from  the  cavity  is  obstructed,  the  amount  of  expectora- 
tion is  diminished  and  fever,  nightsweats,  etc.,  result,  till  the  plug  in 
the  bronchus  is  dislodged,  when  expectoration  begins  and  the  patient 
again  feels  comparatively  w^ell. 

Diagnosis  of  Cavity  in  the  Lung. — If  we  should  accept  the  signs  given 
in  text-books  as  infallible  criteria,  the  diagnosis  of  cavities  is  very 
simple.  But  those  who  often  make  autopsies  and  have  opportunities 
to  verify  their  findings  are  frequently  amazed  at  the  large  number  of 
cavities  found  intra  vitem,  but  missing  at  the  autopsy,  and  the  reverse. 

In  order  that  a  cavity  should  be  discerned  by  physical  explora- 
tion or  even  by  skiagraphy,  it  must  attain  the  size  of  at  least  four 
centimeters  in  diameter;  it  must  be  superficially  located,  filled  with 
more  air  than  secretions  and  communicate  with  a  bronchus.  In  the 
apex  cavities  are  often  missed  because  the  thick,  indurated  pleura 
screens  all  signs.  Some  even  maintain  that  they  must  have  smooth 
walls  if  we  are  to  elicit  by  auscultation  and  percussion  the  signs 
which  are  characteristic  of  excavations.  In  fact,  Walsh,  Landis  and 
others  who  have  studied  the  physical  signs  of  vomicae,  verifying  their 
findings  at  necropsies,  found  that  many  excavations  are  overlooked, 
while  others  that  are  diagnosed  are  not  found  at  the  autopsy.  For 
this  reason  some  believe  that  the  presence  of  elastic  tissue  in  the 
sputum  is  the  best  sign  of  pulmonary  excavation. 

Inspection  and  palpation  are  of  little  value.  The  muscular  atrophy 
noted  over  deep  excavations  above  and  below  the  clavicle  may  be 
seen  in  pulmonary  retraction  without  excavation.  Over  superficial 
cavities,  extreme  atrophy  of  muscles  and  integuments  of  the  area 
overlying  the  excavations  is  very  frequent.  This  atrophy  leaves  the 
chest  wall  over  a  circumscribed  area  very  thin  and,  combined  with 
pleural  adhesions  and  retraction,  may  cause  a  cup-shaped  depression 
localized  over  the  site  of  the  cavity.  But  this  is  comparatively  rare, 
probably  because  many  cavities  are  deeply  situated  within  the  lung. 

Percussion  over  a  cavity  gives  a  dull  note,  and  only  over  large  exca- 
vations superficially  located  in  the  infraclavicular  region  of  emaciated 
patients  and  filled  mostly  with  air,  may  be  obtained  a  hyperresonant 
or  tympanitic  note.  At  most,  we  usually  find  dulness  with  a  tympanitic 
overnote.     But  to  indicate  excavation  even  this  must  be  strictly 


CAVITIES  339 

localized  and  circumscribed.  The  resonance  may  change  within  a 
single  day  from  tympany  to  dulness  when  it  fills  up  with  secretions. 

On  the  whole,  cavitary  tympany  depends  on  many  factors.  In 
young  persons  with  elastic  and  resilient  chest  walls  it  is  more  often 
present  over  small  excavations  than  in  the  aged,  whose  chests  are 
usually  rigid  and  unyielding,  and  even  large  excavations  may  not  be 
tympanitic.  The  more  superficial  the  location,  the  more  pronounced 
the  tympany,  while  deeply  lying  cavities  are  screened  by  air  con- 
taining lung  tissue  and  tympany  is  altogether  absent.  It  is  thus 
evident  that  tympany  is  not  a  constant  sign  of  cavitation,  but  when 
localized,  circumscribed  and  pronounced,  it  speaks  for  a  cavity  of 
large  size  with  greatly  relaxed  walls;  and  conversely  we  find  high 
tympany  over  tight  walls  of  small  cavities.  It  may  best  be  perceived, 
as  Flint  showed  long  ago,  when  the  ear  is  close  to  the  patient's 
mouth,  or  when  the  bell  of  the  stethoscope  is  held  in  this  position. 
Cracked-pot  resonance  is  also  best  perceived  in  this  manner. 

The  most  common  site  of  tympany  due  to  cavitation  is  above  the 
fourth  rib  anteriorly  and  on  rare  occasions  we  find  it  in  the  axillary 
line  beneath  the  fifth  rib,  especially  in  the  left  side,  while  posteriorly 
it  is  exceedingly  rare  because  of  the  large  muscles  which  interfere  with 
percussion.  I  have  met  with  cavities  that  were  tympanitic  over 
three-fourths  of  the  chest  wall,  indicating  excavation  of  almost  an 
entire  lung.  But  this  is  rare  because  in  such  cases  the  mediastinum 
is  pulled  over  and  produces  dulness. 

Occasionally  the  tone  changes  known  as  Wintrich's,  Friedreich's  and 
Gerhardt's  phenomena  are  of  assistance  in  the  diagnosis  of  vomicae, 
but  not  as  frequently  as  some  text-books  would  lead  us  to  believe. 

Wintrich'^  Ijhenomenon,  obtained  by  percussion  while  the  patient 
opens  and  closes  his  mouth,  the  note  being  tympanitic  when  it  is  open, 
and  of  lower  and  deeper  pitch  when  closed,  is  a  good  indication  of  a 
cavity  communicating  with  a  bronchus  and  is  more  distinct,  the 
greater  the  diameter  of  the  bronchus.  It  may  be  obtainable  only  in 
certain  positions  of  the  body  (interrupted  Wintrich),  which  is  clearly 
due  to  the  presence  of  fluid  secretions  within  the  cavity  which  obstruct 
the  opening  of  the  bronchus.  It  is  also  met  with  in  some  cases  of 
bronchiectatic  excavations,  but  this  is  to  be  distinguished  by  the 
location  of  the  cavity — anteriorly  and  above  in  tuberculosis,  and 
posteriorly  and  below  in  bronchiectasis.  It  may  also  be  found  in 
pneumothorax,  but  the  concomitant  symptoms  and  signs  clear  up 
the  diagnosis,  excepting  in  the  localized  and  latent  forms,  which  can 
only  be  recognized  with  the  .r-rays. 

Williams's  tracheal  tone,  observed  while  percussing  the  consolidated 
apex  which  conducts  the  tracheal  tympany,  is  at  times  mistaken  for 
Wintrich's  phenomenon.  It  is  usually  found  in  cases  of  contraction 
or  consolidation  of  lung  tissue  or  its  compression  in  pleuritic  exudates, 
when  percussion  above  and  below  the  clavicle  sets  up  vibrations  in 
the  main  bronchus  and  the  trachea. 


340 


CHRONIC  PHTHISIS— ADVANCED  STAGES 


Friedreich's  phenoinenon  consists  in  high-pitched  tympany  over  the 
site  of  excavations  when  the  patient  holds  his  breath  during  full  inspira- 


Coins 


Coins 


Gerhardt'  phenomenon 


Stethoscope  I 


Interrupted  Wintrich's  J 
phenomenon 


Stethoscope 

Biermer's  phenomenon; 
coin-percussion 

=  shaded  =  fluid 
Clear  space  =  air 


Fig.  67. — Illustrating  Gerhardt's  and  Biermer's  phenomena,  interrupted  Wintrich's 
phenomenon  and  coin-percussion.     (Musser.) 

tion,  diminishing  during  extreme  and  held  expiration.  This  is  not  as 
reliable  as  Wintrich's  sign  because  it  is  at  times  obtained  over  healthy 
lungs. 


Fig.  68.— Illustrating  Gerhardt's  and  Biermer's  phenomena  and  interrupted 
Wintrich's  phenomenon.      (Musser.) 

In  Gerhardt's  'phenomenon  the  note  is  higher  and  more  tympanitic 
when  the  patient  is  sitting  or  standing  than  when  he  is  reclining,  and 
is  said  to  be  characteristic  of  an  oval-shaped  cavity  filled  partly 


CAVITIES  341 

with  fluid  and  partly  with  air,  the  fluid  gravitating  according  to  the 
position  of  the  patient.  Small  cavities,  superficially  located,  occasion- 
ally show  this  sign  and  when  the  excavation  is  centrally  located,  it 
must  attain  considerable  dimensions  to  be  thus  characterized.  As 
Sahli  points  out,  Gerhardt's  phenomenon  is  rare,  and  slight  difterences 
in  the  percussion  note  with  changes  in  position  may  be  within  physio- 
logic limits  due  simply  to  alteration  in  the  tension  of  the  thoracic 
walls  without  any  cavity  within  the  chest. 

In  hydropneumothorax  we  often  observe  Biermer's  'phenomenon, 
which  is  produced  in  the  same  manner  as  Gerhardt's  in  pulmonary 
cavities  (see  Figs.  67  and  68). 

Cracked-pot  resonance,  first  described  by  Laennec,  is  occasionally 
obtained  over  cavities.  Some  precautions  are  necessary  in  order  to 
elicit  this  sign.  The  patient  should  keep  his  mouth  wide  open,  the 
pleximeter  finger  placed  over  the  second  or  third  intercostal  space 
anteriorly,  and  with  the  percussion  finger  a  strong  blow  is  delivered 
without  rebound,  at  the  end  of  expiration.  It  is  apparently  a  stenotic 
murmur  at  the  opening  of  the  cavity  into  a  bronchus  when  the  air  is 
suddenly  expelled  through  a  narrow,  slit-like  opening.  It  may,  how- 
ever, be  met  with  in  many  other  conditions,  as  in  a  crying  child,  and 
in  adults  with  relaxed  lungs,  also  in  emaciated  persons  with  resilient 
chest  walls  and  in  cases  of  small  emphysematous  islands  surrounded 
by  consolidated  lung  tissue  which  are  not  uncommon  in  chronic 
phthisis.  Of  the  many  cavities  that  I  have  seen,  cracked-pot  reson- 
ance was  present  in  but  a  small  proportion.  When  obtained  in  con- 
nection with  some  of  the  other  signs,  it  is  of  significance. 

Cavernous  and  Amphoric  Breathing.^ — Auscultation  may  be  altogether 
negative  over  deeply  lying  vomicae,  or  such  as  are  completely  closed 
by  a  plug  in  the  communicating  bronchus.  Cavernous  breathing  is 
often  heard;  it  resembles  the  sound  produced  while  blowing  into  an 
inclosed  hollow  space.  It  is  caused  by  the  overtones  developed  in  the 
cavity  by  reflection  from  the  walls.  Over  cavities  having  smooth 
walls  communicating  with  a  bronchus  we  often  hear  amphoric  breath- 
ing— a  murmur  with  high  overtones  lacking  deep  basal  tones,  resem- 
bling the  sound  produced  by  blowing  across  the  opening  of  a  narrow- 
mouthed  vase.  Cavernous  and  amphoric  breathing  have  a  certain 
diagnostic  significance.  They  indicate  pulmonary  excavation,  bronchi- 
ectasis, or  pneumothorax.  Formerly  it  was  thought  that  pneumo- 
thorax shows  amphoric  breathing  only  when  it  is  freely  communicating 
with  a  bronchus.  But  now  we  often  find  it  over  artificial  pneumo- 
thorax, and  it  is  then  due  to  reverberation  of  the  bronchial  sounds 
from  the  smooth  pleura.  Over  many  excavations  only  loud  and  harsh 
bronchial  breathing  is  audible. 

Over  areas  with  amphoric  breathing  we  usually  elicit  a  dull  note  on 
percussion  and,  at  times,  cracked-pot  resonance,  while  over  areas 
with  cavernous  breathing  we  often  get  tympanitic  resonance,  though 
not  always,  as  was  already  indicated.     Amphoric  resonance  is  an 


342  CHRONIC  PHTHISIS— ADVANCED  STAGES 

indication  that  the  excavation  is  at  least  five  centimeters  in  diameter, 
that  its  walls  are  smooth,  round  and  rigid  due  to  surrounding  infil- 
tration or  fibrosis;  that  in  all  probabilities  it  communicates  with  a 
bronchus  of  not  very  wide  caliber;  and  that  it  is  not  active — a  fibrous 
capsule  prevents  the  absorption  of  toxic  matter  from  the  cavity,  and 
also  the  extension  of  the  lesion,  and  the  small  amount  of  secretion 
is  soon  eliminated  by  expectoration.  It  is  for  these  reasons  that  cavities 
with  amphoric  breathing  are  usually  not  accompanied  by  any  adven- 
titious sounds,  excepting  at  times  by  a  metallic  tinkle,  and  this  is 
very  rare;  while  cavernous  breathing  is  almost  always  accompanied 
by  large  or  medium  sized,  consonating  rales  or  gurgles.  In  the  latter 
case  the  cavit}'  is  active,  probably  growing  and  not  surrounded  by  a 
fibrous  shell.  The  prognostic  significance  is  clear.  The  intensity  of 
the  amphoric  phenomena  depends  on  the  stiffness  of  the  wall  which, 
in  its  turn,  depends  on  a  strong  fibrous  capsule  or  on  infiltration  and 
caseation  of  the  surrounding  lung  tissue.  In  the  former  case  it  will 
not  enlarge  and  may  even  shrink,  while  in  the  latter  case  the  excava- 
tion may  extend  and  usually  does. 

Metamorphosed  Breathing. — Over  the  sites  of  cavities,  mainly  over 
the  upper  lobes,  we  sometimes  hear  the  inspiratory  murmur  begin  as 
a  harsh  or  bronchial  murmur,  but  during  its  course  suddenly  soften 
and  change  in  tone,  finally  ending  with  an  amphoric  sound.  At  times 
both  inspiration  and  expiration  are  thus  affected.  Laennec  spoke 
of  it  long  ago  as  a  soufle  mile,  beginning  as  vesicular  and  ending  as 
bronchial  or  amphoric.  It  seems  that  it  is  due  to  the  breathing  of  a 
cavity.  The  air  enters  into  a  relaxed  excavation  and  the  murmur 
is  modified  while  its  walls  are  being  distended  or  inflated.  It  is  one 
of  the  best  signs  of  an  excavation,  but  it  is  only  rarely  met  with. 

Adventitious  Sounds  Heard  over  Cavities. — Over  excavations,  large, 
moist,  bubbling,  consonating,  rales — called  in  text-books  metallic  or 
cavernous  rales — are  often  heard.  They  are  caused  by  the  air  stream 
passing  through  the  collection  of  fluid  in  the  excavation.  The  size, 
pitch,  timber  and  duration  of  these  rales  depend  on  the  size  of  the 
vomicae  in  which  they  originate  as  well  as  the  condition  of  its  walls — 
whether  they  are  smooth  or  ragged,  rigid  or  relaxed,  etc.  On  the 
other  hand,  over  old  cavities  there  may  be  audible  amphoric  breathing 
of  an  exquisite  type,  metallic  breathing  without  any  rales  at  all, 
because  the  fibrous  walls  do  not  secrete  any  more.  These  are  cases 
that  are  doing  well  for  years  in  spite  of  extensive  excavations. 

In  many  cases  the  number  of  rales  in  excavations,  and  their  inten- 
sity are  so  great  that  they  obscure  all  the  breath  sounds. 

The  metallic  tinkle  is  only  rarely  heard  over  pulmonary  cavities. 

Pectoriloquy  is  met  with  over  pulmonary  cavities,  but  it  is  not 
pathognomonic  of  this  condition.  In  many  cases  we  hear  the  voice 
as  if  it  is  directly  spoken  into  the  ear  with  abnormal  clearness.  It 
merely  indicates  that  the  conditions  for  conduction  are  unusually 
good,  which  may  be  true  of  excavations,  but  is  also  met  with  in 


CAVITIES  343 

pneumothorax  and  even  in  consolidated  lung  tissue  through  which  a 
bronchus  passes. 

The  same  is  true  of  whispered  pectoriloquy.  But  the  transmission 
of  the  whispered  voice  with  a  metallic  or  amphoric  echo,  which  Kuthy 
calls  "amphorophony,"  is  a  sure  indication  of  a  smooth-walled  cavity 
filled  with  air,  either  pulmonary  or  pleural,  i.  e.,  a  tuberculous  excava- 
tion or  a  pneumothorax.  The  differential  diagnosis  between  these 
two  conditions  can  at  times  only  be  made  out  by  the  a;-rays,  and  I 
have  met  with  cases  in  which  skiagraphy  was  not  decisive.  Some 
cavities  can  be  made  out  by  auscultation  with  much  less  trouble  and 
greater  reliability  than  with  other  diagnostic  methods.  Amphoro- 
phony  is,  however,  only  audible  over  old  and  large  cavities  which 
are  stationary,  while  over  acutely  progressive  and  extending  vomicae 
it  is  not  at  all  heard. 

Basal  Cavities. — The  vast  majority  of  tuberculous  cavities  are  formed 
in  the  upper  lobes  of  the  lungs,  except  in  the  terminal  stages,  when 
the  resistance  is  very  low,  excavations  then  forming  in  the  lower 
lobes  of  the  lungs. 

They  are  very  difficult  of  diagnosis.  We  may  find  signs  of  excava- 
tions at  the  base  which  are  really  "phantom  caverns,"  as  William 
Ewart^  called  them.  The  amphoric  sounds  of  an  excavation  in  the 
upper  lobe  are  transmitted  to  the  base  by  some  transient  or  permanent 
consolidation.  Echo  may  also  be  responsible  for  cavernous  sounds 
at  the  base  when  the  original  excavation  is  situated  in  the  opposite 
side  of  the  chest  and  not  in  immediate  contact  with  the  spinal  column. 

Basal  cavities  are  to  be  differentiated  from  bronchiectasis  and  from 
syphilis  of  the  lungs.  In  bronchiectasis  the  sputum  is  mucopurulent, 
separates  into  three  layers  on  standing,  is  occasionally  putrid,  brought 
up  periodically  in  large  quantities  and  contains  no  tubercle  bacilli. 
But  all  these  may  be  encountered  with  phthisical  cavities.  The  writer 
has  been  guided  by  the  state  of  nutrition  of  the  patient.  If,  in  spite 
of  the  abundant  and  extensive  bronchitis  manifesting  itself  by  profuse 
expectoration  and  numerous  large,  consonating  rales  and  gurgles, 
the  patient  holds  his  own,  the  chances  in  favor  of  bronchiectasis  are 
immense.  Tuberculosis  showing  such  activity  is  accompanied  by 
pronounced  emaciation,  fever,  nightsweats,  and  tubercle  bacilli  are 
not  lacking.  Syphilis  of  the  lung  with  basal  cavities  is  difi'erentiated 
from  tuberculosis  by  the  presence  of  other  stigmata  of  specific  disease, 
the  Wassermann  reaction,  and  the  continued  absence  of  tubercle  bacilli 
from  the  sputum.  Finally,  the  diagnosis  is  at  times  only  cleared  up 
by  the  therapeutic  test — antisyphilitic  treatment  acts  promptly  in 
most  cases. 

It  is  important  to  mention  that  the  prognosis  is  more  unfavorable 
in  basal  cavities  than  in  those  located  in  the  upper  lobes,  undoubtedly 
because  they  do  not  empty  themselves  with  ease.     Considering  a 

^  Goulstonian  Lectures,  Brit.  Med.  Jour.,  1882. 


344  CHRONIC  PHTHISIS— ADVANCED  STAGES 

pulmonary  cavity  as  an  abscess,  we  understand  that  when  it  does  not 
drain  the  result  must  be  disastrous;  the  abundant  secretions  fill  it  up 
and  cough  is  not  very  effective  in  removing  them.  In  the  terminal 
stages  of  phthisis  with  lesions  in  the  upper  lobe,  excavations  sometimes 
form  at  the  base,  as  we  find  them  at  necropsy,  and  kill  the  patient 
who  may  have  been  getting  along  very  well  before  their  occurrence. 
In  fact,  if  in  the  course  of  chronic  phthisis  signs  of  excavation  appear 
in  the  lower  half  of  the  chest,  the  prognosis  is  very  gloomy. 

Visceral  Displacements.— The  displacements  of  the  mediastinal 
organs  have  already  been  referred  to  (p.  335).  The  heart  is  in  most 
cases  of  advanced  phthisis  displaced  toward  the  affected  side  of  the 
chest  and  in  right-sided  lesions  we  at  times  meet  with  complete  dex- 
trocardia. But  in  many  cases  there  are  also  to  be  noted  displacements 
of  the  trachea  and  larynx,  first  described  by  E.  Ruedinger.^  INIore 
recently  Gerald  B.  Webb,  A.  M.  Forster,  and  G.  B.  Gilbert^  described 
in  detail  the  tracheal  position  in  phthisis  and  suggested  an  easj^  method 
of  detecting  it:  By  placing  the  hand  behind  the  neck  while  the  thimab 
anteriorly  reaches  out  to  the  trachea  and  rolls  it,  we  can  in  most  cases 
determine  its  position.  It  appears  that  in  most  cases  of  early  phthisis 
the  trachea  is  displaced  toward  the  affected  side.  Webb  found  in  100 
cases  of  pulmonary  tuberculosis  of  all  stages  the  recognition  of  the 
side  especially  affected  proved  correct  in  69,  doubtful  in  19,  and 
incorrect  in  12  cases.  It  is  due  to  pleural  adhesions,  together  with 
fibrosis  in  the  lung  or  pulmonary  retraction  pulling  the  trachea  along. 

This  deviated  trachea  is  occasionally  a  source  of  error  in  diagnosis. 
When  it  is  displaced  to  the  margin  of  the  sternum,  we  hear  loud  tracheal, 
or  even  "cavernous"  breath  sounds  both  anteriorly  and  posteriorly 
and  thus  diagnose  a  cavity  which  does  not  exist.  Especially  is  this 
error  of  great  moment  when  the  trachea  is  displaced  to  the  opposite 
unaffected  side  after  the  induction  of  a  pneumothorax,  and  we  may 
think  that  there  is  a  cavity  in  the  untreated  lung.  But  a  little  care 
will  usually  clear  up  the  case,  especially  when  the  possibility  of  dis- 
placement of  the  trachea  is  borne  in  mind.  Webb  says  that  movement 
of  the  trachea  to  the  side  of  the  healthier  lung  following  the  application 
of  pneumothorax  foretells  a  successful  application  of  this  procedure. 
In  my  experience  this  is  not  invariably  the  case. 

In  man}^  cases  there  is  also  upward  displacement  of  the  stomach 
and  liver  after  pulmonary  retraction. 

Duration  of  the  Disease. — The  duration  of  chronic  phthisis  is  vari- 
able. Some  patients  get  well  or  succumb  within  one  year,  while  in 
most  the  sluggish  course  continues  intermittently  for  many  years, 
during  which  period  the  patients  consider  themselves  cured,  and 
suffer  from  "relapses"  several  times.  They  constitute  the  bulk  of 
the  class  of  patients  who  are  admitted  to  sanatoriums  and  hospitals 
for  consumptives  several  times.    The  reason  is  clear  when  we  bear  in 

1  Beitr.  z.  Klinik  d.  Tuberkulose,  1910,  xvii,  1.51. 

2  Jour.  Amer.  Med.  Assn.,  1915,  Ixv,  1017. 


DURATION  OF  THE  DISEASE  345 

mind  the  oscillating  course  of  the  disease — during  acute  or  subacute 
exacerbations  they  seek  relief  in  an  institution,  while  during  remis- 
sions, when  the  process  is  quiescent,  they  believe  that  hey  have 
been  cured,  or  the  disease  has  been  arrested. 

Basing  their  estimates  on  heterogeneous  material,  different  authors 
have  estimated  the  average  life  of  the  consumptive  as  at  from  one  to 
ten  years.  Leudet^  found  that  of  hospital  patients  90.7  per  cent,  die 
within  five  years  of  the  onset  of  the  first  symptoms;  9.3  per  cent, 
during  the  sixth  to  the  nineteenth  year.  He  also  found  that  among 
the  more  prosperous  patients  only  77.2  per  cent,  die  within  the  first 
five  years,  and  22.8  per  cent,  between  the  sixth  and  the  nineteenth 
years.  Brown  and  Pope,^  studying  statistically  the  outlook  of  patients 
discharged  from  the  Adirondack  Cottage  Sanitarium,  found  that, 
of  those  discharged  "apparently  cured"  at  the  end  of  five  years, 
94  per  cent,  of  the  expected  were  alive;  at  the  end  of  ten  years,  86 
per  cent.  In  those  "arrested"  the  proportions  for  the  corresponding 
years  were  63, 49,  and  46  per  cent.;  and  for  those  "active,"  25, 15,  and 
10  per  cent.  It  is  thus  clear  that  "an  arrested"  or  even  an  "active" 
case  is  not  necessarily  doomed.  There  are  always  good  chances  to  live 
for  long  years. 

The  striking  disparity  in  these  two  sets  of  statistics  is  due  to  the 
difference  in  the  material.  Leudet  studied  only  fatal  hospital  cases, 
without  including  any  of  those  who  survived  twenty  years,  while 
Brown  and  Pope  studied  cases  discharged  from  a  good  sanatorium  in 
which  moderately  well-to-do  patients  predominate,  and  among  whom 
a  fairly  large  proportion  were  affected  with  the  abortive  type  of  the 
disease. 

Attempts  at  estimating  the  average  duration  of  life  of  the  consump- 
tive have  also  met  with  failure  because  it  is  difficult  to  obtain  com- 
parable material.  When  only  acute,  progressive  cases  are  considered, 
the  average  is  a  low  figure,  one  year  or  even  less;  when  abortive 
cases  are  considered — and  they  are  mostly  those  which  have  been 
diagnosed  exceedingly  early  in  the  disease — the  average  is  very  high. 
It  is  for  this  reason  that  the  estimates  of  "averages"  vary  from  one 
to  ten  years,  according  to  different  authors. 

But  for  the  individual  patient,  with  whom  the  physician  deals, 
averages  do  not  count  for  much.  He  must  be  judged  by  the  clinical 
manifestations.  It  may  be  stated  that  those  who  have  long  periods 
of  quiescence  live  long;  many  practically  their  natural  life.  They 
may  be  "cured"  several  times  when  they  suffer  from  acute  or  subacute 
exacerbations,  but  they  recuperate  every  time  and  live  on,  often 
with  quite  some  efficiency.  On  the  other  hand,  those  in  whom  acute 
or  subacute  exacerbations  are  frequent,  and  each  is  of  long  duration, 
a  fatal  issue  is  inevitable  sooner  or  later. 

1  Quoted  from  Kuthy  and  Wolff-Eisner,  Prognosenstellung  d.  Tuberkulose,  Berlin. 
1914,  p.  56. 

2  American  Medicine,  1904,  viii,  879;    Ztschr.  f.  Tuberkulose,  1908,  xii,  205. 


346  CHRONIC  PHTHISIS— ADVANCED  STAGES 

Modes  of  Death. — Death  supervening  during  an  acute  exacerba- 
tion, when  the  process  in  the  lungs  is  extending,  or  the  toxemia  is 
severe,  or  the  resistance  is  low,  may  be  rapid,  like  from  pneumonia 
or  septicemia.  The  patient  may  have  done  quite  well,  but  is  suddenly 
stricken  with  high  fever  and  prostration,  and  he  succumbs  to  dyspnea, 
cardiac  failure,  etc.  Usually  the  process  is  slower;  the  high  continuous 
or  remittent  fever,  the  profuse  nightsweats,  anorexia,  dysphagia  due 
to  laryngeal  ulceration,  extreme  emaciation,  etc.,  keep  on  for  weeks 
or  months;  the  patient  is  gradually  but  surely  consumed  by  the  dis- 
ease. In  some,  the  last  few  weeks  resemble  in  their  symptomatology 
the  tj'phoid  state  with  marked  prostration,  muttering  delirium,  etc. 

In  others,  the  cachexia  progresses  despite  the  fact  that  the  fever  is 
low,  hardly  ever  exceeding  101°  F.,  and  the  patients  finally  die  from 
asthenia,  like  those  suffering  from  malignant  disease.  Excepting  the 
cough,  diarrhea  and  weakness  they  do  not  suffer  much  and,  because 
the  sensorium  is  well  retained  to  the  end,  the  euphoria  may  be  exquisite. 
Others  consider  themselves  quite  well  despite  the  extreme  emaciation 
and  attempt  to  walk  around,  against  the  advice  of  their  physician  and 
among  them  death  due  to  syncope  may  occur.  Some  of  these  unfor- 
tunates are  occasionally  found  dead  in  bed  in  the  morning.  But  in  such 
cases  it  was  usually  not  syncope  but  a  heavy  dose  of  some  opiate 
which  abolished  the  reflexes,  prevented  cough  and  expectoration,  and 
they  were  drowned  by  their  own  secretions.  Other  causes  of  sudden 
death  during  the  night  are  spontaneous  pneumothorax,  copious 
hemorrhage,  etc.,  killing  before  aid  can  be  summoned. 

Complications  of  the  disease  are  often  responsible  for  a  fatal  issue. 
Among  the  most  important  are  pulmonary  hemorrhage  and  pneumo- 
thorax. While  98  per  cent,  of  patients  who  suffer  from  more  or  less 
bleeding  survive  the  accident,  2  per  cent,  succumb  to  it.  The  patient 
may  feel  comparatively  well,  and  in  fact  consider  himself  on  the  way 
of  recovery  or  even  cured,  when  suddenly  brisk  and  profuse  hemor- 
rhage occurs  and  kills  him.  Emaciated  patients  may  die  as  a  result  of 
suffocation  with  their  own  blood,  being  powerless  to  expel  it  from  the 
chest.  In  others,  the  hemorrhage  may  not  be  fatal,  but  it  is  instru- 
mental in  spreading  the  process  in  the  lung,  causing  bronchopneu- 
monia, which  is  fatal  in  a  few  days  or  weeks. 

Pneumothorax  is  the  cause  of  death  in  about  one  of  150  fatal  cases 
of  phthisis.  This  may  kill  the  patient  within  one  or  two  days,  the 
cause  of  death  being  asphyxia,  or  within  a  few  weeks  or  months 
through  complicating  pyothorax. 

Complicating  laryngeal  tuberculosis  is  responsible  for  the  death  of 
many  patients  through  dysphagia,  dyspnea,  edema  of  the  glottis,  etc. 

Between  5  and  10  per  cent,  of  deaths  from  phthisis  are  preceded  by 
cerebral  symptoms.  Most  of  these  are  due  to  tuberculous  meningitis, 
but  some  are  also  caused  by  uremia,  as  was  already  stated. 

Premonitory  Signs  of  Death. — In  chronic  phthisis  with  tendencies 
to  a  fatal  issue,  it  is  often  very  difficult  to  prognosticate  the  time 


PREMONITORY  SIGNS  OF  DEATH  347 

when  the  end  will  come.  Indeed,  the  more  extensive  the  experience 
of  a  physician  with  this  disease,  the  more  guarded  he  becomes  in 
foretelling  the  day  of  death.  Such  statements  as  "he  cannot  survive 
three  days,"  or  "he  will  surel.y  die  within  a  week,"  etc.,  should  be 
avoided.  Some  patients  keep  on  living  for  weeks  or  months  under 
conditions  which  are  puzzling,  to  say  the  least. 

There  are  symptoms  and  signs  which  may,  however,  be  considered 
precursors  of  death  in  phthisis.  Of  these  we  may  mention :  Dysphagia, 
due  to  laryngeal  ulceration,  when  not  quickly  relieved  by  treatment, 
is  a  sure  indication  that  the  patient  will  not  survive  very  long.  The 
same  is  true  of  profuse  diarrhea  which  cannot  be  controlled  by  treat- 
ment. The  emaciation  is  extreme  and  the  end  comes  rapidly.  But 
I  have  seen  cases  with  profuse  diarrhea  lasting  for  months  in  spite 
of  the  fact  that  they  hardly  assimilated  any  nourishment.  The  reason 
is  clear  when  we  consider  that  the  emaciated  victim  of  phthisis  lies 
quietly,  hardly  moving  a  limb  or  expending  any  energy,  so  that  the 
least  fuel  is  sufficient  to  keep  the  spark  of  life  aglow. 

Edema  of  the  extremities  very  often  appears  shortly  before  death. 
It  is  usually  due  to  cardiac  weakness  or  nephritis,  thrombosis  or 
thrombophlebitis.  It  may  be  unilateral,  but  usually  both  lower 
extremities  are  affected.  The  swelling  may  be  enormous  in  extreme 
cases,  while  in  most  it  is  but  moderate,  and  tender  on  pressure.  When 
this  edema  of  the  lower  extremities  is  combined  with  cyanosis  and 
dyspnea,  a  fatal  issue  may  be  expected  within  a  month.  Thrombosis 
of  the  femoral,  jugular,  subclavian,  or  other  veins  is  one  of  the  surest 
premonitory  signs  of  death. 


CHAPTER  XXI. 
ACUTE  PHTHISIS. 

Just  as  in  other  infectious  diseases,  there  are  observed  in  tuber- 
culosis acute,  malignant  or  fulminating  forms  which  run  a  shorter 
and  almost  invariably  fatal  course.  They  are  relatively  rare,  as 
malignant  scarlet,  measles,  typhoid,  etc.,  are  rare.  Every  practitioner 
meets  with  these  acute  cases  and  the  laity  is  well  aware  of  their 
existence.  When  tuberculosis  makes  its  appearance  in  a  member  of 
a  family  anxious  inquiries  are  made  to  ascertain  whether  it  is  not 
"hasty,"  or  "galloping  consumption,"  the  names  under  which  acute 
tuberculosis  is  commonly  known.  Pathologically,  the  lesion  is  prac- 
tically the  same  as  that  of  the  chronic  forms  of  the  disease,  considering 
that  there  are  no  two  cases  of  phthisis  in  which  the  anatomical  changes 
are  exactly  alike,  but  clinically  it  manifests  itself  by  a  more  rapid 
course,  the  patient  lasting  as  many  months  with  the  acute  form,  as 
years  with  the  chronic  forms.  Acute  tuberculosis  may  be  said  to  be 
active  chronic  phthisis  without  the  remissions  and  ameliorations 
characteristic  of  the  course  of  the  latter  affection. 

It  is  umiecessary  to  enter  into  hair  splitting  distinctions  of  the 
pathological  and  clinical  types  of  acute  phthisis  described  by  some 
authors,  notably  the  French.  In  practice  we  meet  mainly  with  two 
types  of  the  disease:  The  lobar  pneumonic  type — acute  pneumonic 
phthisis,  and  the  lobular  or  bronchopneumonic  type.  In  the  former 
the  patients  are  usually  adults,  while  the  latter  attacks  mainly  infants 
and  very  young  children,  and  adults  only  at  the  terminal  stages  of 
chronic  phthisis. 

Between  the  two  extremes — chronic  and  acute  phthisis — there 
are  many  gradations,  some  are  very  acute,  the  patient  being  carried 
off  within  one  or  two  weeks;  some  are  subacute,  lasting  for  two  to 
four  months,  others  even  a  year,  but  without  any  remissions  in  the 
progress.  Then  there  are  acute  exacerbations  during  the  course  of 
chronic  phthisis  which  are  anatomically  and  clinically  of  the  same 
character  as  the  acute  or  subacute  forms  and  often  bring  hitherto 
hopeful  cases  to  a  speedy  termination.  I  have  also  met  with  cases 
which  began  acutely  and  kept  up  in  that  manner  for  several  weeks, 
but  suddenly  or  by  degrees  took  a  turn  to  the  better  and  the  patient 
passed  through  the  course  of  chronic  phthisis  subsequently. 

Etiology. — The  factors  operative  in  causing  an  acute  and  malignant 
evolution  of  phthisis  in  some  cases,  while  in  the  vast  majority  it  is 
chronic,  slow  and  more  or  less  benign,  are  not  clear.    From  a  careful 


SYMPTOMATOLOGY  349 

study  of  the  cases  met  in  practice  it  appears  that  the  general  condition 
of  the  patient  before  the  onset  of  the  disease  has  no  influence  in  this 
direction.  In  fact,  it  appears,  as  was  already  stated  (see  p.  112), 
that  phthisis  in  those  who  suffered  from  scrofula  during  childhood, 
.or  who  are  descended  from  tuberculous  stock,  is  more  likely  to  run  a 
slow,  sluggish  course.  On  the  other  hand,  we  very  often  meet  with 
acute  phthisis  in  persons  who  have  no  hereditary  taint,  who  have 
been  in  excellent  condition,  and  only  rarely  in  the  weakly  and  decrepit, 
excepting  tuberculous  bronchopneumonia  in  infants. 

The  problem  whether  these  acute  cases  are  invariably  due  to  more 
virulent  strains  of  tubercle  bacilli  has  not  been  solved,  though  there 
appears  to  be  no  evidence  in  favor  of  such  a  view.  Some  authors 
have  held  that  acute  phthisis  is  caused  when  a  tuberculous  cavity 
breaks  through  into  the  lung,  disseminating  the  secretions  containing 
bacilli,  but  this  is  negated  by  the  fact  that  we  meet  numerous  patients 
who  never  coughed  before  the  onset  of  the  acute  disease. 

It  appears  that  individuals  who  have  never  before  been  in  tubercle 
laden  surroundings  are  more  likely  to  develop  acute  phthisis  when 
infected  primarily  after  they  have  passed  the  age  of  childhood,  as  we 
have  already  shown  (see  p.  119).  The  same  "virgin  soil"  is  presented 
by  infants:  when  they  are  infected  with  tuberculosis  they  very  often 
suffer  from  the  acute  forms  of  the  disease,  and  so  do  adults  hailing 
from  rural  districts  where  they  have  not  met  with  tuberculosis,  so 
that  if  infection  takes  place  it  is  primary.  The  explanation  of  these 
phenomena  has  been  discussed  in  a  previous  chapter. 

Acute  Pneumonic  Phthisis.^ — The  anatomical  changes  are  those  of 
pulmonary  tuberculosis  but  the  process  of  caseation  and  liquefaction 
gains  the  upper  hand,  not  being  limited  by  the  conservative  process  of 
fibrosis  which  is  a  strong  feature  in  chronic  phthisis;  no  connective 
tissue  is  formed  to  localize  the  lesion.  Usually  the  greater  part  of  a 
lobe,  or  a  whole  lobe,  is  affected.  The  parenchyma  is  transformed 
into  a  solid,  caseous  or  gelatinous  mass  within  which  there  can  often 
be  found  a  focus  representing  an  old  lesion.  The  destruction  of 
lung  tissue  goes  on  at  a  rapid  pace  and  within  a  short  time  more  or 
less  extensive  excavations  may  be  formed.  But  these  excavations 
are  not  surrounded  by  a  connective-tissue  wall;  all  around  them  is 
caseated  lung  tissue.  In  many  cases,  however,  death  supervenes 
before  softening  has  had  time  to  set  in  and  sequestrate  the  affected 
part  of  the  lung.  We  may  find  scattered  tubercles  or  caseous  nodules 
all  over  the  affected  lung  and  also  in  the  other,  as  well  as  on  the  visceral 
pleura,  but  pleural  adhesions  are  extremely  rare. 

Symptomatology. — The  disease  is  mostly  seen  in  adults  between 
twenty  and  forty  years  of  age.  The  onset  and  symptoms  during  the 
first  few  days  are  akin  to  those  of  lobar  pneumonia.  In  fact,  most  of 
the  cases  of  chronic  phthisis  which  are  said  to  have  begun  as  lobar 
pneumonia  are  cases  of  acute  pneumonic  phthisis  which  were  not 
recognized  as  such  at  the  onset  of  the  acute  stage. 


350  ACUTE  PHTHISIS 

As  given  by  the  patients,  the  onset  is  nearly  always  acute.  After 
some  alleged  exposure  there  was  a  chill,  fever,  pain  in  the  chest,  cough, 
etc.  But  a  careful  inquiry  elicits  that  while  the  acute  symptoms  have 
come  on  suddenly,  the  patient  has  for  weeks,  perhaps  for  months, 
felt  out  of  sorts;  was  unable  to  perform  his  usual  work  without  fatigue; 
in  fact,  he  has  coughed,  expectorated  and  may  have  had  some  night- 
sweats.  But  all  these  symptoms  were  not  sufficiently  pronounced  to 
cause  alarm ;  even  if  he  has  consulted  his  physician  he  may  have  been 
told  that  his  troubles  were  trifling.  This  long  prodromal  stage  is  of 
great  diagnostic  importance,  and  will  often  aid  while  attempting  to 
differentiate  acute  pneumonic  phthisis  from  lobar  pneumonia. 

^Yith  the  acute  symptoms  the  patient  is  laid  up  in  bed.  The  dyspnea 
is  marked  from  the  beginning  and  may  be  paroxysmal.  The  pain  in 
the  side  is  mild  and  only  rarely  as  acute  as  in  pneumonia  or  pleurisy, 
or  may  be  altogether  lacking.  Cough  is  nearly  always  annoying; 
it  may  be  severe,  incessant  and  exhausting.  At  first  dry,  it  slowly 
becomes  productive  and  the  sputum  is  at  times  rusty  and  viscid, 
adhering  to  the  sides  of  the  vessel  like  in  lobar  pneumonia.  But  in 
most  cases  it  is  mucopurulent,  frothy  and  easily  brought  up.  In  some 
cases  it  is  sanguineous,  at  times  repeated,  small,  true  hemoptyses 
take  place,  and  the  disease  may  begin  with  a  profuse  pulmonary 
hemorrhage.  When  softening  and  excavation  take  place,  which  occur 
quite  soon,  the  sputum  is  of  the  same  character  as  that  of  chronic 
phthisis,  excepting  that  it  is  more  often  green  in  color.  In  the  begin- 
ning repeated  microscopic  examinations  do  not  reveal  any  tubercle 
bacilli,  and  because  pneumococci  are  quite  frequent,  the  diagnosis  is 
very  difficult.  Only  after  the  disease  has  lasted  for  a  couple  of  weeks, 
and  very  often  much  later,  and  we  may  be  thinking  that  we  are  dealing 
with  an  unresolved  pneumonia,  tubercle  bacilli  are  discovered  in  the 
sputum. 

Weakness,  anorexia,  emaciation  and  fever  are  very  strong  clinical 
features  in  the  evolution  of  the  disease.  The  weakness  may  be  so 
severe  that  very  early  in  the  course  of  the  disease  the  patient  is  unable 
to  sit  up  in  bed,  or  to  breathe  for  the  purpose  of  auscultation.  When 
examined  they  fall  back  in  bed  exhausted,  pale  and  cyanosed.  This 
asthenia  is  not  seen  in  the  average  case  of  lobar  pneumonia.  With  the 
anorexia,  which  may  be  pronounced  from  the  very  beginning,  emacia- 
tion goes  hand  in  hand.  Even  in  the  few  cases  in  which  the  appetite 
is  somewhat  retained,  the  emaciation  is  very  early  and  pronounced, 
and  out  of  proportion  to  the  fever  and  anorexia.  It  usually  proceeds 
rapidly  and  often  frightfully,  so  that  within  a  few  weeks  a  normally 
built  man  is  reduced  to  a  skeleton.  Wasting  is  particularly  quick  in 
the  muscles  of  the  chest. 

In  the  beginning  the  fever  is  of  a  continuous  type,  like  in  lobar 
pneumonia,  though  some  authors  have  described  i)neumonic  phthisis 
without  high  fever,  which  I  have  never  met  in  my  practice.  But  this 
is  rare  during  the  first  few  weeks  when  the  temperature  curve  ex- 


DIFFERENTIAL  DIAGNOSIS  351 

quisitely  simulates  that  of  lobar  pneumonia,  but  during  the  second 
week,  when  we  expect  defervescence,  we  are  disappointed.  Instead 
of  this,  the  fever  becomes  intermittent  or  hectic,  with  morning 
remissions  to  normal  or  even  below,  and  afternoon  rises  to  103°  or 
104°  F.,  and  accompanied  b}'^  copious  nightsweats.  The  pulse  is  rapid, 
small  and  feeble,  and  the  blood-pressure  low.  The  full,  vigorous  pulse 
of  lobar  pneumonia  is  never  found. 

Physical  Signs. — Physical  exploration  of  the  chest  often  shows  the 
signs  of  typical  lobar  pneumonia.  There  is  impaired  resonance  or 
dulness  over  the  upper  part  of  one  side  of  the  chest  above  the  third 
rib.  But  instead  of  the  harsh  tubular  breathing  which  is  character- 
istic of  pneumonia,  we  usually  perceive  diminished  and,  in  some 
cases,  complete  absence  of  breath  sounds,  which  are  replaced  by  moist, 
subcrepitant  rales.  The  crepitation  of  pneumonia  is  only  rarely 
audible.  With  the  advance  of  the  lesion  the  dulness  becomes  more 
pronounced  and  the  respiratory  murmur  may  be  altogether  abolished, 
or  bronchial  breathing  may  become  audible  coupled  with  small  and 
medium-sized  moist  rales.  In  acutely  progressive  cases  signs  of  exca- 
vation may  be  found  within  four  weeks,  but  this  is  rare. 

Course. — In  most  cases  the  acute  symptoms  persist  for  two  or  three 
months,  the  lesion  softens,  extensive  excavations  may  form  and  the 
patient  finally  succumbs  to  asthenia.  In  some  the  process  is  of  shorter 
duration;  I  have  seen  two  cases  in  which  death  occurred  in  less  than 
three  weeks.  On  rare  occasions  the  disease  is  acute  for  four  to  six 
weeks,  when  an  improvement  in  the  general  condition  takes  place  and, 
with  more  or  less  extensive  excavation  in  a  lung,  the  patient  becomes 
a  chronic  consumptive  and  the  disease  may  even  be  arrested  in  time, 
which  is,  however,  very  rare.  In  some  the  toxemia  is  very  severe  and 
the  patient  succumbs  within  two  or  three  weeks,  even  before  softening 
has  taken  place.  The  prognosis  under  the  circumstances  is  very  grave, 
the  average  duration  of  the  fatal  cases,  and  they  are  in  the  vast 
majority,  is  about  six  weeks,  dying  from  toxemia  and  exhaustion. 

Differential  Diagnosis. — It  is  often  very  difficult  to  differentiate 
acute  pneumonic  phthisis  from  lobar  pneumonia,  especially  during 
the  first  tw€  weeks  of  the  ailment.  Mistakes  may  be  avoided  by 
carefully  inquiring  for  premonitory  symptoms  of  tuberculosis  pre- 
ceding the  acute  onset,  such  as  anorexia,  emaciation,  weakness,  mild 
cough,  nightsweats,  etc.,  which  are  frequent  in  acute  phthisis,  while 
in  lobar  pneumonia  the  patient  is  stricken  suddenly  when  he  feels  in 
the  best  of  health.  In  fact,  in  atypical  pneumonia,  acute  tuberculosis 
is  always  to  be  thought  of.  The  absence  of  pain  in  the  side,  the  late 
arrival  of  true  bronchial  breathing,  the  hemoptysis,  etc.,  may  all  lead 
to  a  diagnosis  or  at  least  a  suspicion  of  acute  phthisis.  An  irregular 
temperature  curve,  mild  dyspnea,  severe  pallor,  low  leukocyte  count, 
absence  of  pneumococci  from  the  sputum  and  a  strong  diazo-reaction 
may  also  be  considered.  Of  great  importance  in  favor  of  acute 
phthisis  is  yellow  or  green  sputum.     Tubercle  bacilli  are  conclusive 


352  ACUTE  PHTHISIS 

evidence,  but  they  are  only  rarely  found  before  the  end  of  a  month. 
During  the  jQrst  week  the  emaciation  is  negligible  in  pneumonia 
irrespective  of  the  acuteness  of  the  symptoms,  while  in  phthisis  it  is 
immediately  pronounced;  nightsweats,  weakness  and  edema  of  the 
lower  limbs  are  frequent.  The  crisis,  which  is  sure  to  come  before  the 
fourteenth  day  in  the  vast  majority  of  cases  of  pneumonia  will  clear 
up  doubtful  cases. 

Especially  difficult  is  the  diagnosis  of  pneumonic  phthisis  in  aged 
persons  in  whom  it  may  occur  without  much  fever  and  other  general 
symptoms  and  only  positive  sputum  can  decide. 


TUBERCULOUS  BRONCHOPNEUMONIA.    GALLOPING 
CONSUMPTION. 

Etiology. — -The  anatomical  changes  in  tuberculous  bronchopneu- 
monia are  those  of  pulmonary  tuberculosis,  excepting  that  the  lesion 
is  not  localized  in  one  apex,  or  one  lobe,  but  disseminated  all  over  one 
or  both  lungs  in  which  there  are  distributed  caseous  nodules  which 
vary  in  size  from  that  of  a  pin-point  to  that  of  a  walnut.  Some  authors 
have  been  inclined  to  attribute  the  wide  dissemination  of  the  lesion, 
as  well  as  the  acute  course  of  this  form  of  tuberculosis,  to  mixed  in- 
fection with  tubercle  bacilli  and  pyogenic  microorganisms.  This, 
they  believe,  is  confirmed  by  the  fact  that  it  very  often  follows  in- 
fections such  as  measles,  whooping-cough,  influenza,  typhoid,  etc., 
showing  that  the  patient  had  harbored  a  tuberculous  process  before, 
but  with  the  addition  of  a  new  infective  agent  his  vitality  was  re- 
duced and  the  tuberculous  process  allowed  to  spread  all  over  the 
lungs.  But  against  this  view  may  be  brought  forward  the  numerous 
cases  in  which  mixed  infection  can  be  positively  excluded. 

In  most  cases  it  appears  to  be  the  result  of  the  wide  dissemination 
of  the  contents  of  a  tuberculous  cavity  in  the  lungs,  or  the  perforation 
of  a  tuberculous  lymph  node,  the  contents  of  which  are  aspirated, 
carried  all  over  the  bronchial  tree  and  take  root  in  various  parts  of  the 
lungs.  In  infants,  among  whom  this  form  of  the  disease  is  very  common, 
it  may  be  due  to  a  primary  massive  infection  with  tubercle  bacilli; 
the  body  possessing  no  immunity  through  previous  infection,  the 
result  is  the  same  as  when  a  guinea-pig  is  infected.  In  adults,  we  also 
meet  it  after  copious  pulmonary  hemorrhages,  childbirth,  in  tuber- 
culosis with  diabetes  and  alcoholism,  etc.,  when  the  resisting  powers 
are  at  low  ebb,  and  immunity  acquired  by  the  existing  lesion  is  lacking. 

Symptoms. — Tuberculous  bronchopneumonia  in  adults  is  usually 
found  in  patients  who  have  been  tuberculous  for  some  time.  In 
those  in  whom  it  appears  to  be  of  sudden  onset,  careful  inquiry  elicits 
the  information  that  the  patient  has  been  ailing  for  some  time  with 
symptoms  highly  suggestive  of  tuberculosis.  In  fact,  it  is  often  a 
complication  of  chronic  phthisis:     A  patient  who  has  been  doing 


TUBERCULOUS  BRONCHOPNEUMONIA  353 

fairly  well  suddenly  develops  acute  symptoms  without  any  special 
cause;  more  often  after  a  profuse  pulmonary  hemorrhage  or  a  surgical 
operation  in  which  a  general  anesthetic  was  employed.  Tuberculous 
women  are  frequently  the  victims  soon  after  childbirth. 

The  clinical  picture  is  that  of  an  acute  infectious  disease  with  pro- 
nounced toxemia.  The  onset  is  sudden,  often  with  a  chill,  fever, 
backache,  cough,  expectoration,  etc.  The  fever  is  usually  high — 
103°  to  104°  F.  is  not  uncommon — and  in  children  it  may  be  even 
higher.  The  temperature  curve  is  not  characteristic;  in  fact,  it  may 
be  stated  that  its  characteristic  is  its  irregularity.  In  many  cases 
it  is  continuous  with  slight  remissions,  but  in  others  it  is  intermittent, 
with  chills  before  each  rise.  During  the  terminal  stages  it  is  usually 
hectic.  The  sweats  are  profuse  and  exhausting,  the  pulse  feeble, 
small  and  rapid,  120  to  150  is  not  rare;  the  dyspnea  is  marked — 40 
to  60  per  minute  are  very  often  counted  and  cyanosis  is  a  frequent 
feature.     Graves  spoke  of  "acute  tubercular  asphyxia." 

The  intensity  of  the  cough  is  variable :  In  some  patients  it  is  severe, 
painful,  paroxysmal  and  may  provoke  vomiting.  While  occassionally 
the  cough  is  mild,  in  most  cases  it  is  more  severe  than  in  chronic 
phthisis.  At  times  expectoration  is  absent  or  scanty,  but  usually  it 
is  more  or  less  abundant,  often  purulent,  and,  with  the  advance  of  the 
disease,  nummular,  yellowish  green  balls  are  brought  up.  Tubercle 
bacilli  are  found  in  most  cases. 

Hemoptysis  is  frequent  in  adults  and  may  be  quite  copious;  many 
cases  begin  with  pulmonary  hemorrhage. 

The  appetite  is  rarely  fairly  well  retained,  but  in  most  cases  this, 
as  well  as  the  digestive  functions,  are  impaired,  many  have  to  be  coaxed 
to  take  some  nourishment.  Emaciation  proceeds  at  a  rapid  pace. 
Because  of  the  flushed  face  it  is  at  times  not  appreciated  at  first  sight, 
but  when  the  bedclothes  are  removed,  the  marked  wasting  of  the 
subcutaneous  tissues  and  muscles  of  the  chest  and  extremities  presents 
a  frightful  picture,  especially  when  it  is  considered  that  it  may  have 
been  consummated  within  a  few  weeks. 

Physical  Signs. — The  physical  signs  vary  according  to  the  nature 
of  the  anatomical  changes  in  the  lungs.  In  the  beginning  they  may 
be  obscure  and  misleading.  In  most  cases  the  note  elicited  on  per- 
cussion is  hyperresonant  all  over  the  two  sides  of  the  thorax;  localized 
dulness  is  found  only  later  when  some  of  the  disseminated  tubercles 
have  become  confluent.  Auscultation  shows  either  feeble  breathing 
or  harsh  bronchovesicular  breath  sounds  all  over  the  chest  coupled 
with  sibilant  and  sonorous  rales.  With  the  advance  of  the  disease, 
which  may  be  within  but  one  or  two  weeks,  we  find  localized  areas, 
not  necessarily  in  the  apex,  especially  in  children,  of  consolidation 
with  bronchial  breathing  and  moist  subcrepitant  rales  which  soon 
change  their  character  when  excavation  takes  place  and  the  usual 
signs  of  a  cavity  can  be  made  out.  In  many  cases,  notably  in  children, 
signs  of  diffuse  bronchitis  are  found  all  over  the  chest,  while  in  others 
23 


354  ACUTE  PHTHISIS 

the  toxemia  is  so  severe  that  the  patient  succumbs  before  definite 
changes  in  the  resonance  and  breath  sounds  have  developed. 

Complications. — Among  these  may  be  mentioned  pulmonary 
hemorrhage,  which  may  be  fatal;  intestinal  tuberculosis,  tuberculous 
meningitis  and  general  miliary  tuberculosis. 

Diagnosis. — The  diagnosis  is  very  difficult  in  the  initial  stages 
particularly  in  children  among  whom  it  must  be  differentiated  from 
postgrippal  bronchopneumonia  and  sputum  is  not  available  for 
microscopic  examination.  In  adults  it  is  usually  more  easily  diag- 
nosticated. We  find  in  patients  who  have  been  tuberculous  for 
some  time  that  after  a  hemorrhage,  surgical  anesthesia,  pregnancy, 
etc.,  the  symptoms  suddenly  take  a  sharp  turn  and  galloping  con- 
sumption follows.  It  is  always  to  be  borne  in  mind  that  when  in  a 
person  who  never  before  had  emphysema,  and  who  has  no  barrel- 
shaped  chest,  symptoms  and  signs  of  emphysema  suddenly  make 
their  appearance  accompanied  by  acute  constitutional  symptoms 
such  as  fever,  cough,  nightsweats,  etc.,  acute  phthisis  is  to  be  thought 
of.  The  sputum  will  soon  clear  up  the  diagnosis.  With  the  advance 
of  the  disease  the  physical  signs  are  easily  made  out. 

Prognosis. — The  prognosis  is  very  grave.  Some  acute  cases  run 
a  rapid  course  terminating  fatally  within  four  or  six  weeks,  and  in 
children  in  a  shorter  time.  Many  cases  linger  for  three  or  four  months 
and  die  of  asthenia.  I  have  met  some  cases  in  which  the  disease  came 
to  a  halt  and  assumed  the  character  of  chronic  phthisis. 


CHAPTER  XXII. 
FIBROID  PHTHISIS. 

Fibrous  Hyperplasia  in  Phthisis. — Discussing  the  morbid  anatomy 
of  phthisis,  we  showed  that  while  the  tuberculous  process  is  mainly 
one  of  destruction — infiltration,  caseation  and  softening — there  are 
reparative  forces  at  work  in  almost  every  case,  manifesting  themselves 
principally  in  the  formation  of  connective  tissue  which  either  heals 
the  lesion  through  cicatrization,  or  at  least  limits  its  progress.  In  fact, 
it  may  be  said  that  without  the  formation  of  connective  tissue,  every 
case  of  phthisis  would  be  acute.  The  balance  between  the  destructive 
and  reparative  processes  in  phthisis  depends  consequently  on  the 
amount  of  fibrosis  within  and  about  the  lesion — the  more  intense  the 
formation  of  fibrous  tissue,  the  slower  the  progress  of  the  disease  and 
conversely  the  less  the  fibrosis  the  more  acute  and  progressive  the 
disease. 

We  must  distinguish  between  fibrosis  and  formation  of  cicatrices. 
When  a  lesion  cicatrizes,  the  activity  of  the  tuberculous  focus  is 
extinguished,  though  w^ithout  any  restitutio  ad  integrum,  as  is  seen  in 
healed  tuberculous  lesions  of  the  lungs  and  pleura.  But  in  fibrosis 
the  lesion  is  an  active,  inflammatory  process,  though  it  may  be  only 
slightly  progressive,  yet  connective  tissue  is  being  continually  produced. 
In  other  words,  in  fibroid  phthisis  the  destructive  process  is  smoulder- 
ing though  in  abeyance,  or  entirely  absent  and  the  proliferative  pro- 
cess dominates.  As  Bard  says,  the  lesions  may  be  progressive  and 
spreading,  though  they  are  not  of  a  destructive  character. 

It  must  also  not  be  confused  with  fibroid  degeneration  of  the 
pulmonary  parenchyma  which  at  times  follows  acute  or  chronic 
non-tuberculous  inflammatory  processes  of  the  lungs,  such  as  the 
so-called  interstitial  pneumonia,  pulmonary  induration  or  cirrhosis,  etc. 
Fibroid  phthisis  is  a  specific  proliferation  of  the  lung  tissue  caused 
by  tubercle  bacilli. 

Clinically  this  form  of  tuberculosis  is  characterized  by  an  exceed- 
ingly chronic  course  extending  over  many  years,  finally  leading  in 
most  cases  to  the  development  of  the  symptoms  and  course  of  the  com- 
mon form  of  chronic  phthisis.  It  differs  from  other  forms  of  inflam- 
matory fibrous  degenerations  of  the  lung  in  that  it  is  caused  by  the 
tubercle  bacilli  and  that  the  characteristic  tuberculous  giant  cells  are 
found  microscopically  in  the  lesions  of  fibroid  phthisis. 

Fibroid  phthisis  was  mentioned  by  Bayle  one  hundred  years  ago 
and  ever  since  by  many  others;    Sir  Andrew  Clark^  coined  the  terra 

1  Fibroid  Diseases  of  the  Lung,  London,  190G. 


356  FIBROID  PHTHISIS 

and  made  a  thorough  study  of  the  pathology  and  symptomatology  of 
the  disease.  C.  J.  B.  and  C.  T.  Williams/  in  their  book  on  consump- 
tion, also  give  a  complete  description  of  this  form  of  phthisis.  Of 
the  more  recent  writers  who  treat  of  this  subject,  may  be  mentioned 
Bard,2  Sokolowski/  and  Piery."*  "While  most  of  the  authors  do  not 
agree  on  the  various  points  which  characterize  fibroid  phthisis,  yet  in 
the  main  they  are  in  agreement  on  its  differentiation  from  all  other 
forms  of  pulmonary  tuberculous  disease. 

Etiology. — Fibroid  phthisis  is  mainly  encountered  inpersons  between 
forty  and  sixty  years  of  age  and,  contrary  to  the  statements  of  many 
authors,  it  may  occur  in  younger  individuals.  Apparently  many  cases 
are  treated  for  chronic  bronchitis,  asthma,  pulmonary  emphysema, 
etc.,  and  only  after  the  process  has  lasted  for  many  years  is  the  char- 
acter of  the  affection  recognized;  an  intercurrent  hemorrhage  or 
tubercle  bacilli  in  the  sputum  reveals  the  true  nature  of  the  disease. 
I  have  met  with  many  cases  in  persons  under  thirty  years  of  age. 

It  appears  that  syphilis  is  an  important  etiological  factor;  when 
both  tuberculosis  and  syphilis  are  met  with  in  the  same  individual,  the 
process  of  the  former  is  often  of  the  fibroid  type.  Sergent-^  and  several 
other  French  writers  have  indeed  maintained  that  most  fibroid  cases 
are  a  manifestation  of  syphilis  and  tuberculosis.  Several  English 
authors  hold  the  same  view.  Thus,  J.  Mitchell  Bruce^  says:  "It 
should  be  noted  that  some  cases  of  quiescent  phthisis  give  a  history 
of  syphilis  which  may  account  for  the  disposition  to  fibrosis,  and 
pro  tanto  may  be  a  favorable  element  prognosticaUy."  In  my  expe- 
rience, this  holds  true  for  some  cases  but  not  for  the  majority.  I  have 
seen  many  cases  of  fibroid  phthisis  in  which  specific  disease  was  posi- 
tively excluded,  and  at  the  INIontefiore  Home,  where  we  have  many 
of  these  cases,  the  Wassermann  reaction  is  only  rarely  positive  and 
the  other  stigmata  of  syphilis  are  lacking  in  the  majority  of  cases 
of  fibroid  phthisis. 

English  authors,  notably  Clark,  have  observed  that  the  gouty 
diathesis  which  is  antagonistic  to  tuberculosis  is  responsible  for  the 
fibroid  form  of  phthisis.  This  is  not  in  agreement  with  mj^  experience, 
because  among  the  poor  in  New  York  City  gout  is  rather  rare,  while 
fibroid  phthisis  is  quite  common.  Xor  have  I  found  any  etiological 
relations  between  fibroid  phthisis  and  alcoholism,  or  social  and  eco- 
nomic conditions,  etc. 

It  appears  to  me  that  occupation  is  of  greater  etiological  moment, 
^lost  of  the  cases  I  have  seen  were  in  persons  working  indoors,  inhal- 
ing animal  and  vegetable  dust — garment-workers,  furriers,  rag-pickers, 


'  Pulmonarj'  Consumption,  London,  1887. 

2  Forms  cliniques  de  la  tuberculose  pulmonaire,  classification  et  description  sommaire 
Geneve,  1901. 

^  Klinik  dcr  Brustkrankheiten,  Berlin,   1906,  ii,  410. 

■*  La  Tuljerculose  pulmonaire,  Paris,  1910. 

^  Presse  Medicale,  1908,  xvi,  657.  « Lancet,  1013,  i,  591. 


FORMS  OF  FIBROID  PHTHISIS  357 

etc.  It  seems  also  that  chronic  lead  poisoning  is  a  predisposing  factor, 
because  of  its  frequency  among  plumbers,  printers  and  house  painters. 
In  former  days  it  was  frequently  seen  among  chimney  sweeps,  and 
today  it  is  met  with  among  those  who  inhale  any  irritative  dust,  as 
knife-grinders,  coal-heavers,  button-makers,  etc. 

Pathology. — The  pathology  of  fibroid  phthisis  has  been  thoroughly 
studied  by  Sir  Andrew  Clark,  who  described  that  the  affected  lung  is 
usually  decreased  in  size,  sometimes  its  dimensions  do  not  exceed  the 
size  of  a  closed  fist.  In  local  fibrosis  only  the  affected  part  of  the  lung 
may  be  contracted  while  the  rest  fills  up  its  place  by  compensatory 
emphysema.  Cavities — pulmonary  and  bronchiectatic — are  common, 
surrounded  by  dense,  rigid  walls.  Cheesy  nodules  encapsulated  by 
fibroid  tissue  are  frequent,  and  during  the  final  stages  the  caseating 
process  gains  the  upper  hand  and  breaks  through  the  limiting  and 
protective  fibrous  tissue  spreading  the  destructive  process.  The 
walls  of  the  alveoli  are  thickened  and  finally  obliterated  or  filled  in, 
the  interlobar  connective  tissue,  especially  around  the  large  vessels  and 
bronchi,  proliferates  enormously  and,  replacing  the  parenchymatous 
tissue  of  the  lung,  produces  a  state  of  induration  through  which  the 
dilated  bronchi  pass. 

In  all  cases  of  fibroid  phthisis  the  pleura  is  thickened  over  the 
affected  area,  sometimes  attaining  a  thickness  of  one-half  to  three- 
fourths  of  an  inch.  The  pleural  cavity  is  adherent  and,  in  the  pleural 
form,  obliterated  by  tough  fibrous  tissue  binding  the  two  surfaces 
together,  and  from  it  other  bands  of  connective  tissue  are  sent  forth 
into  the  lung  which  contract  and  drag  along  toward  the  affected  side 
the  mediastinum,  the  diaphragm,  and  with  it  the  liver,  etc. 

We  are  not  clear  why  the  tubercle  bacilli  produce  caseation  and 
liquefaction  of  tissue  in  most  cases,  while  in  others  a  proliferation  of 
connective  tissue  is  the  dominant  feature  after  infection.  We  know 
that  in  many  cases  of  fibroid  phthisis  we  have  an  additional  etiological 
factor,  the  inhalation  of  mineral,  animal,  and  vegetable  dust.  But 
on  the  other  hand,  the  form  which  will  be  described  as  the  pleural 
form  of  fibroid  phthisis  is  not  usually  associated  with  the  inhalation 
of  irritating  dust,  but  the  causative  factor  seems  to  be  bacterial,  plus 
the  predisposing  factors  which  are  operative  in  the  other  forms  of 
chronic  phthisis. 

We  are  in  the  dark  about  these  problems.  It  has  not  been  proven 
that  in  fibroid  phthisis  the  tubercle  bacilli  are  of  some  attenuated 
strain,  or  of  the  bovine  type.  In  many  cases  of  fibroid  phthisis  in  which 
tubercle  bacilli  are  not  detected,  Much's  granules  have  been  found, 
thus  pointing  to  bacilli  which  have  lost  their  acid-fast  properties, 
being  the  cause;  but  this  also  requires  further  study. 

Forms  of  Fibroid  Phthisis. — The  symptomatology  of  fibroid  phthisis 
depends  on  the  form  of  the  disease.  My  experience  is  in  agreement 
with  that  of  Sokolowski,  excepting  that  I  meet  with  a  pleural  form  in 
addition  to  his  two  forms — simple  fibroid  phthisis  and  fibroid  phthisis 


358  FIBROID  PHTHISIS 

with  emphysema.  The  most  common  clinical  form  encountered  by 
me  is  the  emphysematous. 

The  Emphysematous  Form, — The  patient  has  usually  been  a  chronic 
cougher,  expectorated  for  years  and  felt  short-winded,  especially  on 
exertion,  as  climbing  stairs.  He  may  have  consulted  physicians 
repeatedly  and  was  informed  that  the  trouble  was  not  of  serious  import; 
that  it  was  chronic  bronchitis,  pulmonary  emphysema,  etc.  Inas- 
much as  he  has  been  able  to  pursue  his  occupation,  he  more  or  less 
disregarded  the  cough,  expectoration,  dyspnea,  etc.  During  the 
winter  and  autumn  these  patients  are  usually  subject  to  "colds," 
"grippe,"  etc.,  when  the  cough  is  aggravated  and  persists  for  several 
weeks  with  greater  severity  than  usual. 

In  some  patients,  especially  those  engaged  in  trades  involving  the 
inhalation  of  animal  or  vegetable  dust,  the  signs  of  pulmonary  emphy- 
sema, as  well  as  attacks  simulating  essential  asthma  are  apt  to  come 
on  suddenly  in  one  .who  has  never  before  suffered  from  any  respiratory 
trouble.  In  fact,  experience  has  taught  me  to  look  with  grave  sus- 
picion on  each  case  of  emphysema  or  asthma  coming  on  suddenly  in 
a  person  over  thirty  years  of  age. 

During  the  early  stages  of  the  disease,  and  this  may  last  for  many 
years,  the  patient,  though  coughing  and  suffering  from  mild  dyspnea, 
pursues  his  vocation  without  interruption.  Fever  is  lacking,  excepting 
during  an  acute  exacerbation  or  some  intercurrent  affection.  The 
expectoration  is  scanty;  in  fact  the  cough  is  usually  dry,  or  some  glairy 
mucus  is  brought  up  after  a  fit  of  coughing.  A  search  for  tubercle 
bacilli  is  usually  fruitless.  But  the  dyspnea  is  annoying  and  increases 
on  slight  exertion. 

The  general  appearance  of  the  patient  is  that  of  a  healthy  person, 
the  panniculus  adiposis  is  well  preserved,  and  in  those  who  do  not 
work  at  hard  manual  labor  and  in  women,  we  may  meet  with  marked 
obesity.  The  "fat  phthisis"  of  which  we  spoke  above  is  seen  almost 
exclusively  in  fibroid  patients.  On  the  other  hand,  there  are  some 
patients  who  are  more  or  less  emaciated,  but  they  are  usually  indi- 
viduals who  have  never  been  fat;  but  even  they  gain  rapidly  after  the 
physician  urges  them  to  rest  and  feed  up.  I  have  met  with  some  who 
have  gained  twenty  or  even  more  pounds  in  a  couple  of  months  and 
retained  it  for  years. 

The  vast  majority  of  fibroid  patients  have  clubbed  fingers  and  curved 
nails.  The  most  exquisite  forms  of  drumstick  fingers  may  be  found 
among  them,  while  they  are  not  so  common  among  those  who  suffer 
from  common  chronic  phthisis. 

Many  get  along  fairly  well  for  years  without  suspecting  the  real 
nature  of  their  trouble,  until  they  are  suddenly  seized  by  attacks  of 
hemoptysis  which  may  be  slight,  or  quite  profuse,  but  which  usually 
frighten  them  out  of  their  wits.  In  some,  the  hemoptysis  is  quite 
frequent  and  may  at  times  be  copious,  while  in  most  it  is  rare  and 
consists  only  in  one  or  two  mouthfuls  of  blood  or  streaky  sputum. 


COURSE  OF  THE  DISEASE  359 

It  may  appear  suddenly  while  the  patient  has  considered  himself  in 
excellent  condition.  It  may  recur  at  irregular  intervals.  Hemor- 
rhagic phthisis  usually  is  fibroid  phthisis  and  most  patients  bear  the 
bleeding  very  well  indeed.  I  had  one  patient  who  was  so  used  to 
hemoptysis  that  it  no  longer  frightened  him.  We  meet  with  some  who 
never  expectorated  blood. 

Well-to-do  patients  without  profuse  hemoptysis  get  along  for  years 
without  troubling  themselves  about  the  cause  of  their  mild  cough 
and  dyspnea  unless  they  apply  for  life  insurance,  and  after  they  are 
rejected  for    'lung  trouble"  they  promptly  consult  a  physician. 

Physical  Signs. — A  physical  exploration  of  the  chest  usually  reveals 
an  emphysematous  or  barrel-shaped  chest  in  those  who  suffered  for 
years,  while  in  those  who  have  only  recently  acquired  the  disease, 
the  thorax  may  be  of  normal  shape.  Careful  inspection  shows  some 
flattening  of  the  supraclavicular,  infraclavicular  and  supraspinous 
fossae,  more  marked  on  one  side  of  the  chest;  wasted  muscles  of  the 
neck  and  shoulder,  and  shoulder  droop  on  the  same  side,  coupled  with 
lagging  and  restricted  motion.  On  percussion,  defective  resonance, 
or  even  dulness  is  elicited  on  one  side  above  the  second  or  third  rib 
anteriorly  and  posteriorly,  while  below,  and  all  over  the  opposite  side 
of  the  chest  the  note  is  hyperresonant  or  slightly  tympanitic,  and  the 
inferior  margin  of  the  lung  is  one  or  two  inches  lower  than  normal 
and  hardly  mobile.  Narrowing  of  Kronig's  resonant  area  can  easily 
be  made  out;  in  fact  it  appears  somewhat  exaggerated  because  the 
opposite  unaffected  apex  is  larger,  owing  to  emphysema.  Auscultation 
shows  feeble  breathing  all  over  the  chest,  while  over  the  site  of  the 
dulness  the  expiratory  murmur  is  harsh  and  prolonged,  at  times  show- 
ing a  bronchial  timbre.  Dry  crackles  or  rales  after  cough  may  be 
audible,  in  others  sibilant  or  sonorous  rales  are  heard  all  over  one  side 
of  the  chest.  During  one  of  the  asthmatic  attacks,  which  in  some 
patients  are  quite  frequent,  so  that  they  are  treated  for  asthma,  we 
hear  wheezing,  sibilant  and  sonorous  rales  all  over  the  chest,  exquis- 
itely simulating  bronchial  asthma. 

Course  of  the  Disease. — These  patients  get  along  quite  well  till 
they  pass  middle  age.  Most  of  them,  if  they  are  under  medical  care 
at  all,  are  considered  individuals  who  are  troubled  with  chronic  bron- 
chitis, pulmonary  emphysema,  asthma,  etc.  But  sometimes  between 
the  age  of  forty  and  sixty,  though  exceptionally  I  have  seen  it  in 
younger  individuals,  the  clinical  picture  changes.  They  begin  to  lose 
weight  gradually  but  persistently,  so  that  sooner  or  later  they  present 
the  unmistakable  appearance  of  the  average  consumptive  in  the 
advanced  stages  of  the  disease.  The  cough  becomes  more  severe 
and  productive  of  globular  and  nummular  sputum  containing  tubercle 
bacilli  and  elastic  tissue,  etc.  The  cyanosis  and  the  dyspnea  become 
more  and  more  marked,  and  finally  orthopnea  sets  in  with  signs  and 
symptoms  of  dilatation  of  the  right  heart  which  is  almost  constant  at 
this  stage,  followed  by  edema  of  the  lower  extremities,  hydrothorax, 


360  FIBROID  PHTHISIS 

etc.  Intestinal  and  laryngeal  tuberculosis  are  quite  common,  and 
contribute  to  the  misery  of  the  patients  who  finally  expire  from 
asystole  or  inanition. 

The  signs  in  the  chest  do  not  differ  markedly  from  those  met  with 
in  the  usual  case  of  far  advanced  phthisis — signs  of  cavitation  at  the 
apices  as  well  as  of  diffuse  bronchitis  are  common.  Skiagraphy,  which 
in  previous  stages  showed  only  signs  of  emphysema  with  some  retrac- 
tion of  one  or  both  apices,  now  reveals  more  or  less  extensive  cavities 
and  peribronchial  infiltration.  Displacements  of  the  mediastinum  are 
more  frequent  than  in  common  chronic  phthisis. 

Diagnosis. — In  the  later  stages  of  the  disease  the  diagnosis  is  clear 
and  it  differs  from  that  of  chronic  phthisis  mainly  because  of  the 
dyspnea,  cyanosis,  edema  and  clubbed  fingers,  which  are  not  as  com- 
mon or  less  marked  in  the  latter  condition.  In  the  earlier  stages, 
however,  fibroid  phthisis  is  difficult  to  dift'erentiate  from  pulmonary 
emphysema,  chronic  bronchitis  and  at  times  from  bronchial  asthma. 
The  persistently  negative  sputum  is  especially  perplexing.  Errors 
may,  however,  be  reduced  to  a  minimum  by  carefully  examining  the 
apices  m  each  case  of  chronic  bronchitis  and  pulmonary  emphysema. 
^Yhenever  the  physical  signs  point  to  infiltration  of  an  apex,  fibroid 
phthisis  is  to  be  thought  of.  The  s^TQptoms  and  signs  of  asthma  com- 
ing on  suddenly  in  one  who  works  in  surroundings  laden  with  animal, 
vegetable,  or  mineral  dust,  usually  point  to  fibroid  phthisis. 

Simple  Fibrosis. ^ — These  are  cases  of  fibroid  phthisis  in  which  the 
onset,  course  and  termination  of  the  disease  are  practically  the  same 
as  in  the  form  just  described,  excepting  that  the  symptoms  of  pul- 
monary emphysema  are  lacking.  The  onset  is  slow  and  insidious. 
The  patient  is  troubled  with  an  occasional  morning  cough,  expectorates 
little  or  nothing,  and  the  sputum  contains  no  tubercle  bacilli  or 
elastic  tissue.  There  is,  however,  slight  dyspnea  on  exertion  which  is 
often  overlooked. 

The  general  condition  of  the  patient  leaves  little  or  nothing  to  be 
desired.  He  has  no  fever,  no  nightsweats,  no  anorexia,  emaciation, 
etc.  All  he  complains  of,  if  at  all,  is  that  he  is  subject  to  "colds," 
especially  during  the  winter  months;  that  he  is  short-winded,  and  of 
hemoptysis,  which  may  be  quite  a  feature  in  this  form  of  phthisis 
when  occurring  often,  or  is  copious.  But  before,  during,  and  imme- 
diately after  the  hemoptysis  there  is  usually  no  fever,  and  convalescence 
is  rapid.  In  fact  many  of  the  patients  feel  much  relieved  after  the 
effects  of  a  brisk  pulmonary  hemorrhage  have  passed  away.  These  are 
the  cases  which  some  English  authors  have  described  as  "arthritic" 
or  "gouty'  hemoptysis  (see  p.  195),  because  some  of  these  patients, 
though  not  all,  present  some  of  the  stigmata  of  the  arthritic  diathesis. 

Many  of  these  patients  present  themselves  to  their  physician  who 
makes  a  careless  examination  of  the  chest  and,  finding  no  sign  of  tuber- 
culous infiltration,  assures  them  that  the  bleeding  came  from  a  ruptured 
bloodvessel  in  the  throat,  etc.    Thus  reassured,  they  return  to  work, 


DIAGNOSIS  361 

feeling  quite  well.  However,  in  many  there  are  signs  of  active  phthisis 
in  one  of  the  apices:  Impaired  resonance,  contraction  of  Kronig's 
resonant  area,  harsh  bronchovesicular  or  distinctly  bronchial  breath 
sounds,  more  or  less  numerous  rales,  all  localized,  circumscribed  and 
persistent  above  the  second  rib  anteriorly  and  posteriorly  over  the 
supraspinous  fossa  in  one  side  of  the  chest.  The  physician  is  often 
amazed  to  find  the  patient  in  such  excellent  condition  for  years  despite 
the  signs  of  a  distinct  and  active  pulmonary  lesion,  and  is  apt  to 
attribute  it  to  chronic  apical  catarrh. 

In  other  cases  the  onset  is,  however,  not  so  insidious.  A  fairly 
healthy  person  is  suddenly  seized  with  a  pulmonary  hemorrhage  which 
may  be  slight,  moderate  or,  rarely,  copious;  or  he  may  develop  mild 
fever,  nightsweats,  cough  and  expectorate  sputum  containing  tubercle 
bacilli.  A  physical  exploration  of  the  chest  shows  a  typical  lesion  of 
moderate  extent.  Inasmuch  as  for  several  weeks  the  patient  presents 
most  of  the  symptoms  and  signs  of  progressive  phthisis,  even  hectic 
fever,  nightsweats,  emaciation,  etc.,  a  grave  or  doubtful  prognosis  is 
rendered. 

But  slowly  the  condition  of  the  patient  begins  to  improve ;  the  fever 
abates,  the  cough  is  ameliorated  or  ceases  altogether,  the  appetite 
improves  and  the  patient  gains  in  weight  considerably,  so  that  in  a 
few  months  his  weight  exceeds  that  found  before  the  onset  of  the 
disease.  He  considers  himself  cured.  But  a  physical  examination  of 
his  chest  shows  distinct  and  unmistakable  signs  of  a  smouldering 
tuberculous  lesion  in  one  apex;  in  fact  all  the  signs  of  active  disease 
are  there.  Feeling  well,  the  patient  reenters  his  occupation  and  works 
quite  efficiently,  believing  that  the  physician  who  declared  him  still 
actively  tuberculous  is  an  alarmist.  I  have  had  patients  of  this  class 
who  have  been  doing  well  for  years  and  came  around  to  the  office  to 
"prove"  it  to  me.  Many  are  of  the  class  discharged  from  sanatoriums 
as  improved  or  even  "unimproved,"  and  inquiry  in  later  years  shows 
that  a  large  proportion  remain  in  good  condition  and  working,  except 
for  more  or  less  pronounced  dyspnea  which  annoys  them. 

After  some  years  the  symptoms  are  gradually  aggravated,  they 
complain  they  have  "caught  a  new  cold,"  which  is  difficult  to  cure. 
The  cough  is  persistent  and  exhausting,  the  dyspnea  distressing,  and 
they  begin  to  lose  in  weight  and  strength  progressively,  presenting 
clearly  the  characteristic  clinical  picture  of  chronic  phthisis  with  its 
usual  complications,  plus  dilatation  of  the  right  heart,  dyspnea  and 
orthopnea.  Physical  exploration  of  the  chest  shows  the  usual  clinical 
picture  of  cavitary  phthisis,  but  there  is  in  addition  bronchitis,  which 
is  unusual  ■  in  chronic  phthisis.  It  differs,  however,  from  chronic 
phthisis  by  the  fact  that  fever  is  lacking  or  at  most  some  insignifi- 
cant elevation  of  temperature  is  noted  at  times.  No  nightsweats  are 
present,  or  only  slight,  at  the  end  of  the  disease. 

Pleural  Form  of  Fibroid  Phthisis. — In  the  pleural  form  of  fibroid 
phthisis,   which  has   been   graphically   described   by  Williams,   the 


362  FIBROID  PHTHISIS 

patient  usually  gives  a  history  of  an  attack  of  pleurisy  with  effusion, 
from  which  he  has  recovered  after  a  longer  or  shorter  illness,  the  fluid 
having  been  absorbed  spontaneously  or  was  aspirated.  But  ever  since 
he  has  remained  with  a  dry,  hacking  cough,  productive  of  little  or  no 
sputum,  and  in  spite  of  the  great  care  he  has  been  taking  of  himself, 
he  has  not  succeeded  in  recuperating  completely.  Dyspnea  is  marked 
and  increasing  steadily  in  intensity.  In  many  cases  the  cyanosis  of 
the  fingers  and  face  is  very  pronounced. 

During  recent  years  I  have  met  with  some  cases  of  this  type 
following  artificial  pneumothorax,  A  pleural  efi^usion  was  slow  in 
disappearing  and  the  gas  inflations  had  to  be  discontinued.  But 
the  patient  kept  well  on  the  road  to  recovery,  remaining  with  a 
pleuropulmonary  tuberculous  lesion. 

Examination  shows  distinct  immobility  of  the  lower  half  of  the  side 
of  the  chest  in  which  the  effusion  had  taken  place  some  retraction  of 
the  chest  wall  and  scoliosis,  or  kyphoscoliosis.  Mensuration  shows 
that  the  affected  side  has  fallen  in — the  circumference  being  smaller 
than  the  unaffected  side  by  more  than  one  inch.  Vocal  fremitus  is 
absent  over  that  area.  On  percussion  we  find  dulness,  at  times  even 
flatness  not  unlike  that  over  pleural  effusion,  which  is  at  once  sus- 
pected. This  is  apparently  confirmed  by  the  absence  of  the  vocal 
fremitus  and  of  any  breath  sounds,  while  in  some  we  hear  distinct 
tubular  or  even  cavernous  breathing.  There  may  be  no  adventitious 
sounds,  but  occasionally  some  medium-sized  or  large,  moist  and  con- 
sonating  rales  and  gurgles  are  audible  during  both  phases  of  respira- 
tion.   At  times,  distinct  friction  sounds,  grating  and  grunts  are  heard. 

On  the  unaffected  side  signs  of  pulmonary  emphysema  are  found — • 
hyperresonance  and  the  inferior  margin  of  the  lung  extends  two  to 
four  inches  lower  than  on  the  opposite  side  owing  to  emphysema,  and 
the  pulmonary  retraction  and  upward  displacement  of  the  diaphragm 
on  the  affected  side  accentuates  it.  Anteriorly,  the  border  of  the 
unaffected  lung  extends  well  over  the  sternum. 

The  heart  is  almost  invariably  dislocated  toward  the  affected  side 
which  serves  as  a  good  sign  of  differentiation  from  pleural  effusion 
,  with  which  it  may  be  confounded,  because  in  effusions  the  dislocation 
is  invariably  toward  the  unaffected  side,  if  at  all.  In  left-sided  lesions 
we  may  find  the  apex  as  far  out  as  the  axillary  line  and  one  or  two 
interspaces  higher  than  the  normal;  in  right-sided  lesions  the  apex 
may  be  found  at  the  xyphoid  cartilage,  or  even  farther  to  the  right. 
It  is  in  these  forms  of  phthisis  that  acquired  dextrocardia  is  at  times 
found.  It  is  due  to  traction  of  the  heart  by  fibrous  bands  in  the  right 
pleura  and  lung  and  also  to  the  pressure  exerted  by  the  vicariously 
emphysematous  left  lung.  The  shrinkage,  as  well  as  the  fibrous  bands 
in  the  lungs  also  drag  the  diaphragm  upward  and,  when  the  right 
side  is  affected,  the  liver  is  also  elevated.  In  the  left  side  the  stomach 
may  be  elevated  along  with  the  diaphragm.  Pulmonary  retraction  m 
the  left  side  also  exposes  the  heart  and  brings  it  near  the  chest  walls 


PROGNOSIS  IN  FIBROID  PHTHISIS  363 

where  we  may  see  it  pulsating.  These  conditions  may  be  made  out  by 
careful  percussion,  but  in  many  cases  the  aid  of  skiagraphy  is  neces- 
sary to  clear  up  mooted  points. 

There  are  other  clinical  peculiarities  which  should  be  mentioned. 
Fever  is  usually  absent  throughout  the  course,  excepting  when  due 
to  some  intercurrent  affection.  When  we  find  a  persistent  elevation 
of  temperature  we  may  look  for  some  complication,  especially  an 
infiltration  of  the  opposite,  hitherto  unaffected  lung.  The  cough, 
which  was  moderate  for  a  long  time,  in  some  cases  for  years,  becomes 
more  and  more  severe  and  the  amount  of  sputum  brought  up  may  be 
enormous.  Both  the  cough  and  the  expectoration  may  be  influenced 
by  posture— the  patient  coughs  more  when  lying  on  one  side  and  some- 
what relieved  when  turning  on  the  other  side,  just  as  in  bronchiectasis. 
This,  however,  gives  no  clue  as  to  which  side  is  affected.  The  sputum 
contains  tubercle  bacilli  in  large  numbers  and  is  at  times  fetid,  which 
is  rare  in  other  forms  of  phthisis. 

Hemoptysis,  which  is  very  frequent  in  other  forms  of  fibroid  phthisis, 
is  less  often  encountered  in  the  pleural  form.  But  when  occurring,  it 
is  apt  to  last  for  days  or  weeks  and  at  times  it  is  copious,  I  have  seen 
two  cases  in  which  it  was  the  cause  of  death  of  patients  who  were 
otherwise  getting  along  very  well. 

The  dyspnea,  which  is  a  feature  of  all  forms  of  fibroid  phthisis  is 
more  severe  in  this  type  because  of  the  loss  of  lung  tissue  and  the  dis- 
placement of  the  heart.  In  fact  I  have  seen  many  cases  in  which  the 
lesion  in  the  lung  was  practically  healed,  or  at  least  distinctly  inactive, 
yet  the  dyspnea  was  severe  and  even  unbearable.  Another  feature 
is  cardiac  palpitation,  especially  in  left-sided  lesions,  which  is  apt  to 
be  so  severe  as  to  make  life  unbearable. 

In  the  terminal  stages  signs  of  cardiac  dilatation  set  in,  edema  of 
the  lower  extremities,  enlargement  of  the  liver,  cyanosis,  etc..  and  the 
patient  dies  from  asystole.  In  many  cases  complications  are  respon- 
sible for  the  final  outcome — hemorrhage,  which  was  already  men- 
tioned, inanition  due  to  laryngeal  tuberculosis  with  dysphagia,  amy- 
loid degeneration  of  the  various  visceral  organs,  etc.  Tuberculosis 
of  the  previously  unaffected  lung  may  bring  about  a  rapid  course  of 
the  disease. 

I  have  observed  that  some  of  these  cases,  tuberculous  in  origin  as 
they  are,  become  purely  bronchiectatic.  The  tubercle  bacilli  disap- 
pear from  the  sputum,  but  the  patient  continues  to  cough  and  expecto- 
rate large  quantities  of  sputum  which  shows  all  the  characteristics  of 
sputum  in  bronchiectasis;  in  fact,  the  course  is  that  of  non-specific 
bronchiectasis  after  this  occurrence. 

Prognosis  in  Fibroid  Phthisis. — As  regards  duration  of  life,  fibroid 
phthisis,  though  an  active  tuberculous  disease  and  hardly  ever  cured, 
is  more  favorable  than  the  other  forms  of  phthisis  excepting  abortive 
tuberculosis.  It  is  among  the  fibroid  patients  that  we  find  individuals 
who  have  been  tuberculous  for  years.    I  have  some  who  have  lasted 


364  FIBROID  PHTHISIS 

for  twenty-five  years,  and  Sokolowski  reports  one  who  lasted  for  more 
than  forty  years.  While  they  are  always  ailing,  many  are  still  fit  to 
pursue  their  vocation,  and- 1  have  among  my  clientele  some  who  have 
worked  quite  hard  without  long  interruptions. 

In  fibroid  phthisis,  the  reparative  processes  of  nature  are  more 
active  than  the  destructive  tuberculous,  and  the  patients  are  shielded 
from  the  extension  of  the  caseating  and  softening  processes,  the 
fibrous  tissue  usually  forming  a  wall  around  the  lesion  limiting  its  prog- 
ress and  preventing  the  absorption  of  toxins,  as  is  evident  from  the 
absence  of  fever,  etc.  Because  of  the  pleural  adhesions  the  patients 
are  shielded  from  such  complications  as  spontaneous  pneumothorax, 
which  never  occurs  among  them.  When  in  my  hospital  practice  I 
once  found  a  fibroid  patient  presenting  the  symptoms,  of  spontaneous 
pneumothorax,  it  was  soon  clear  that  the  rupture  occurred  in  the 
lung  which  had  been  unafi'ected,  but  recently  showed  a  new  lesion. 


CHAPTER  XXIII. 
ABORTIVE  TUBERCULOSIS. 

Natural  Resistance  Against  Phthisis. — As  was  already  shown,  infec- 
tion with  tubercle  bacilli  is  harmless  to  the  vast  majority  of  civilized 
people;  the  lesion  cicatrizes  more  or  less  quickly  without  producing 
distinct  clinical  symptoms.  During  childhood,  when  most  infections 
occur,  the  morbidity  and  mortality  from  this  disease  are  insignificant. 

We  cannot  recognize  these  mild  or  abortive  infections  clinically, 
except  by  the  tuberculin  test;  they  probably  pass  as  slight  or 
severe  "colds,"  grippe,  bronchitis,  etc.  Nor  do  we  know  whether 
they  are  due  to  the  inoculation  by  strains  of  bacilli  of  low  virulence, 
considering  the  marked  difference  in  virulence  displayed  by  var- 
ious strains  of  tubercle  bacilli.  The  suggestion  that  they  may  be  due 
to  infection  with  bovine  bacilli  appears  to  have  much  in  its  favor,  but 
this  also  has  not  been  proven. 

We  meet  at  times  cases  of  abortive  tuberculosis,  i.  e.,  patients  in 
whom  the  disease,  instead  of  pursuing  the  usual  clinical  course  to  its 
termination  in  death  or  recovery  after  several  months'  or  years' 
Ulness,  is  aborted  within  a  few  weeks  or  months  of  indisposition. 
In  other  words,  just  as  we  at  times  meet  with  cases  of  abortive  pneu- 
monia, typhoid,  scarlet  fever,  etc.,  so  is  there  a  form  of  pulmonary 
tuberculosis  which  is  of  relatively  short  duration  and  invariably  termi- 
nates in  recovery.  In  these  cases  the  lesion  is  apparently  circumscribed, 
of  little  activity,  often  altogether  latent  and  quickly  cicatrizes,  and 
when  the  patient  dies  from  any  other  cause  it  is  found  at  the  autopsy 
in  the  shape  of  more  or  less  extensive  scars  located  at  the  extreme 
apex,  pleural  adhesions,  or  even  isolated  fibrous  or  calcareous  nodules 
which  hardly  caused  any  inconvenience  to  their  owners  during  life. 

In  the  older  works  on  phthisis,  this  form  of  tuberculosis  is  not  men- 
tioned at  all.  In  former  days  only  advanced  phthisis  was  recognized. 
But  in  recent  years,  since  Bard^  described  the  pathology  and  sympto- 
matology of  tiiherculose  abortive,  many  others  have  mentioned  it  more 
or  less  extensively.  In  the  second  edition  of  Cornet's^  treatise,  also 
in  Bandelier  and  Ropke's  book,  as  well  as  in  Minor's  article  in  Klebs' 
treatise,  we  find  it  mentioned  cursorily,  while  Piery^  in  his  book 
devotes  an  extensive  chapter  to  it.  Bezanyon^  and  the  present  author' 
have  published  papers  on  the  subject  of  abortive  tuberculosis. 

Abortive  tuberculosis  is  responsible  for  a  large  proportion  of  "non- 
tuberculous"  cases  in  sanatoriums — the  lesion  heals  very  quickly  and 

1  Formes  cliniques  de  la  tuberculose  pulmonaire,  Geneve,  1901. 

2  Die  Tuberkulose,  Vienna,  1907,  p.  690. 

^  La  tuberculose  pulmonaire,  Paris,  1910,  p.  491. 
^Bull.  See.  intern,  hop.  de  Paris,  1901,  p.  933. 
6  Medical  Record,  1913,  Ixxxii,  921. 


366  ABORTIVE   TUBERCULOSIS 

it  is  often  suspected  that  the  patients  were  admitted  through  an 
error  in  diagnosis.  Many  of  the  patients  who  state  that  well-known 
physicians  have  considered  them  tuberculous  at  one  time,  but  that  they 
have  none  the  less  been  healthy  all  along  for  years,  have  in  fact  been 
affected  with  the  abortive  type  of  the  disease  at  the  time  the  diagnosis 
was  made.  I  have  seen  many  patients  who  applied  for  admission  to 
public  sanatoriums  and  were  passed  by  the  admitting  physicians  as 
eligible  incipient  cases,  but  inasmuch  as  the  institutions  were  over- 
crowded, they  had  to  wait  for  weeks  or  months  for  vacant  beds. 
When  they  were  finally  called,  it  was  found  that  all  the  symptoms 
and  signs  of  the  disease  had  vanished.  A  large  proportion  of  cases  of 
"persistent  colds,"  grippe,  rhinopharyngitis,  etc.,  are  also  abortive 
tuberculosis.  If  they  were  carefully  studied,  we  would  discover  some 
physical  signs  in  the  chest  substantiating  this  view.  In  fact,  L.  Napo- 
leon Boston^  reports  finding  tubercle  bacilli  in  cases  of  acute  colds, 
influenza,  bronchitis, 'etc.,  but  the  patients  recovered  without  becoming 
tuberculous.    Many  of  these  were  in  fact  abortive  tuberculosis. 

Symptomatology  of  Abortive  Tuberculosis. — The  symptoms  and 
signs  of  abortive  tuberculosis  are  the  same  as  those  of  incipient  phthisis, 
but  they  never  pass  beyond  that  stage.  In  most  cases  it  begins  with 
the  symptoms  of  a  common  "cold."  After  some  exposure  the  patient 
begins  to  cough,  has  some  fever,  malaise,  backache,  etc.,  and  is  treated 
for  coryza,  grippe,  tonsillitis,  etc.  But  instead  of  ameliorating  within  a 
few  days  or  a  week,  the  symptoms  persist  for  a  month  or  two.  In  many 
cases  the  onset  is  marked  by  hemoptysis.  The  patient,  who  has  felt 
quite  well,  or  at  most  has  coughed  for  a  few  days,  suddenly  feels  some 
irritation  in  the  throat  and  coughs  out  some  blood  or  blood-streaked 
sputum.  The  bleeding  may  last  for  a  few  hours  or  days  and  either 
stops  abruptly  or  continues  for  a  few  days  in  the  form  of  streaky 
sputum.  Every  physician  has  among  his  clientele  patients  who  have 
expectorated  blood  years  ago,  but  have  felt  well  all  along.  While  in 
many  of  these,  the  hemorrhage  was  of  extrapulmonary  origin,  as  was 
already  shown,  in  others  it  was  due  to  abortive  tuberculosis. 

When  the  thermometer  is  carefully  and  judiciously  used,  we  find 
fever  of  a  mild  type;  especially  in  the  afternoon  there  is  a  rise  of  one 
or  two  degrees  and  in  the  early  morn'ng  there  may  be  some  subnor- 
mal temperature.  In  some  cases  that  came  under  my  observation  I 
found  the  typical  temperature  curve  of  mild  incipient  phthisis,  and 
there  were  many  of  the  accompanying  symptoms  of  hyperthermia — 
malaise,  languor,  pain  in  limbs,  backache,  etc.  While  the  patient  is 
not  completely  incapacitated,  yet  he  feels  tired  during  the  afternoon, 
but  recuperates  in  the  evening  or  feels  refreshed  after  a  night's  sleep. 
Nightsweats  are  rare,  but  in  a  few  I  have  noted  that  they  were  drench- 
ing. The  appetite  is  usually  retained,  and  when  the  patient  is  told 
to  eat  well  and  plenty,  he  finds  no  difficulty  in  following  instructions. 

Cough  is  a  constant  symptom;    though  many  state  that  they  do 

1  Interstate  Med.  Jour.,  1914,  xxi,  330. 


PHYSICAL  SIGNS  367 

not  cough,  careful  inquiry  reveals  that  they  clear  their  throat  in  the 
morning.  We  often  meet  with  dry,  hacking  cough  which  is  an  annoy- 
ance during  the  day  and  keeps  the  patient  awake  during  the  night. 
Occasionally  the  cough  is  productive  of  glairy  mucus,  but  the  muco- 
purulent sputum  of  phthisis  is  never  seen  in  abortive  cases,  unless 
there  is  some  rhinopharyngitis. 

Most  abortive  cases  are  of  the  "closed"  variety  of  tuberculosis,  but 
now  and  then  we  meet  with  one  showing  tubercle  bacilli  in  the  sputum. 
The  albumin  reaction  of  the  sputum  is  almost  invariably  positive  in 
these  cases,  and  I  consider  it  of  diagnostic  importance.  Edward  G. 
Glover^  found  that  the  complement-fixation  test  for  tuberculosis  is  of 
value  in  the  determination  of  the  nature  of  some  of  the  dubious  cases. 

In  some,  we  meet  with  hoarseness  lasting  intermittently  for  a  few 
hours  during  the  day,  or  for  several  days  in  succession. 

Tachycardia  is  not  a  very  frequent  symptom,  but  we  very  often  find 
instability  of  the  pulse;  the  least  exertion  or  excitement  raises  its 
rate  to  90  or  more  per  minute.  The  blood-pressure  is  usually  lower 
than  normal.  With  the  improvement  in  the  condition  of  the  patient 
both  the  pulse  and  the  blood-pressure  become  normal  again. 

Physical  Signs. — The  objective  signs  are  those  of  incipient  phthisis. 
Of  course,  when  the  lesion  is  limited  and  centrally  located,  we  may 
not  find  any  physical  signs  at  all  and  without  hemoptysis  and  tubercle 
bacilli  in  the  sputum,  the  diagnosis  cannot  be  made.  In  all  proba- 
bilities the  vast  majority  of  tuberculous  infections  in  man  are  of  this 
character.  They  are  aborted  without  revealing  themselves  in  any 
way.  But  in  those  in  whom  the  conglomeration  of  tubercles  is  large 
enough  to  alter  the  air  content  in  a  limited  area  of  the  lung,  we  may 
find  signs  on  percussion  and  auscultation. 

A  short  note  above  and  immediately  beneath  the  clavicle  is  quite 
common.  But  this  may  be  obscured  by  vicarious  emphysema,  hyper- 
function  or  relaxation  of  the  surrounding  lung  tissue  which  may  emit 
a  hyperresonant  note.  Shortening  of  an  apex,  or  narrowing  of  Kronig's 
resonant  areas  is  more  common  and  can  be  easily  made  out  with 
careful  percussion. 

On  auscultation  we  may  hear  feeble  breath  sounds  over  the  site  of 
the  lesion,  or  rough,  interrupted,  cog-wheel  breathing.  Only  the 
inspiratory  murmur  is  usually  altered,  but  I  have  seen  cases  in  which 
the  expiratory  murmur  was  prolonged,  and  even  bronchovesicular 
in  character,  indicating  extensive  infiltration,  yet  recovery  went  on 
speedily,  showing  that  even  a  considerable  focus  may  be  aborted. 
This  is  confirmed  by  the  large  scars,  or  encapsulated  and  calcified 
tubercles  found  at  times  while  making  autopsies  on  persons  who  died 
from  causes  other  than  tuberculosis. 

Adventitious  sounds  are  not  often  heard  excepting  in  those  who 
have  had  hemoptysis  and  in  some  grippal  cases,  in  which  dry  crackles 
or  crepitation  may  be  audible  during  inspiration  and  influenced  by 

1  Quarterly  Journal  of  Medicine,  1915,  viii,  339. 


368  ABORTIVE  TUBERCULOSIS 

cough.  Of  course,  to  be  of  significance,  these  signs  must  be  strictly 
locaUzed  at  one  apex,  and  constant  for  some  time.  They  must  also 
be  differentiated  from  spurious  rales,  as  well  as  from  marginal  sounds. 

Skiagraphy  is  of  little  value  as  was  already  stated  in  Chapter  XVII. 

Diagnosis.— These  are  the  classical  symptoms  and  signs  of  incipient 
phthisis,  and  when  meeting  with  a  case  we  are  by  no  means  certain 
as  to  the  course  the  disease  is  likely  to  take.  In  fact,  many  abortive 
cases  are  admitted  to  sanatoriums  where  they  are  speedily  cured, 
and  they  contribute  no  small  portion  of  the  statistical  success  of 
institutional  treatment. 

In  the  progressive  cases  the  lesion  extends  and  the  constitutional 
symptoms  become  more  and  more  marked  within  a  few  months,  while 
in  the  abortive  forms  the  mild  fever,  cough,  nightsweats,  etc.,  abate 
within  a  few  weeks  or  one  or  two  months,  and  the  physical  signs  dis- 
appear, or  they  are  superceded  by  sibilation  and  there  may  permanently 
remain  a  prolonged  expiratory  murmur  over  the  affected  apex.  While 
in  most  cases  the  local  impairment  of  resonance  remains,  and  for  this 
reason  there  are  many  persons  in  whom  there  are  differences  in  this 
regard  when  the  two  apices  are  compared,  I  have  observed  that  in 
some  even  this  disappears,  to  be  replaced  by  slight  hyperresonance, 
due  probably  to  hyperfunction,  the  result  of  vicarious  emphysema 
of  lung  tissue  around  the  cicatrix  which  was  caused  by  the  healing 
process. 

Without  observing  the  patient  for  several  weeks,  and  without  an 
initial  pulmonary  hemorrhage,  or  tubercle  bacilli  in  the  sputum, 
abortive  tuberculosis  cannot  be  diagnosticated,  because  there  always 
lurks  a  suspicion  that  it  may  have  been  a  non-tuberculous  apical  lesion. 
There  are,  however,  some  points  which  may  help  us  in  recognizing 
this  form  of  tuberculosis:  When  a  patient  with  an  apical  lesion  has 
a  good  appetite,  and  normal  gastric  function,  gaining  weight  and 
strength  as  soon  as  he  begins  to  take  care  of  himself,  there  is  a  likeli- 
hood that  the  lesion  may  be  aborted  and  cured  within  two  or  three 
months.  However,  this  may  prove  deceptive  at  times.  Some  points 
which  have  helped  me  are  the  following:  A  slow  pulse,  not  much 
influenced  by  exertion  or  excitement,  speaks  for  a  benign  process. 
The  initial  hemoptysis  of  chronic  phthisis,  as  was  already  stated,  is 
usually  preceded  by  cough,  weakness,  nightsweats,  etc.,  for  weeks 
before  the  bleeding,  while  in  abortive  cases  this  is  rare — the  hemoptysis 
comes  like  a  thunderbolt  out  of  a  clear  sky,  without  any  premonitory 
symptoms  and  without  any  apparent  exciting  cause.  In  progressive 
cases  the  initial  hemoptysis  is  usually  more  abundant,  and  always  fol- 
lowed by  fever  of  the  type  described  above.  In  abortive  tuberculosis  the 
temperature  remains  normal  at  times,  but  usually  it  is  slightly  elevated, 
1°  or  1.5°  for  a  couple  of  weeks.  Initial  hemoptysis  of  tuberculous 
origin  without  high  or  moderate  fever,  and  without  tachycardia, 
weakness,  languor,  etc.,  points  to  an  abortive  lesion. 

In  the  majority  of  cases,  however,  only  careful  observation  of  the 
course  of  the  affection  is  decisive. 


CHAPTER  XXIV. 
PULMONARY  TUBERCULOSIS  IN  CHILDREN. 

General  Characteristics  of  Tuberculosis  in  Children. — In  children 
infection  with  tubercle  baciUi,  if  it  causes  active  disease  at  all,  is 
usually  followed  by  a  generalized  morbid  process  with  implication  of 
the  lymphatic  glands.  This  characteristic  is  the  more  accentuated 
the  younger  the  child.  In  fact,  in  all  infectious  diseases  we  may  note 
that  the  reaction  of  the  lymphatic  glands  is  intense  in  children.  The 
glands  are  particularly  sensitive  to  tuberculosis. 

The  localized  disease  of  the  lungs  peculiar  to  phthisis  in  adults, 
or  in  the  bones  and  joints,  characteristic  of  early  childhood,  is  never 
seen  in  infants.  "  In  children  who  have  passed  the  seventh  or  eighth 
year  the  pathological  process  resembles  that  seen  in  adults,"  says 
'Holt,i  "but  in  younger  children,  and  especially  in  infants,  nothing 
corresponding  to  it  is  met  with."  In  infants  tuberculosis  is  an  acute, 
general  infection,  like  typhoid  or  septicemia,  and  when  the  bacilli 
localize  themselves  by  metastasis  in  any  part,  they  produce  lesions 
akin  to  those  of  pyemia. 

Because  of  the  implication  of  the  glandular  system,  especially  the 
intrathoracic  glands,  it  was  assumed  by  many  authors  that  infection 
in  children  is  invariably  accomplished  by  inhalation  of  the  bacilli. 
The  microorganisms  are  deposited  in  the  lungs,  and  when  attempting 
to  invade  the  blood,  they  are  retained  by  the  lymphatic  glands.  When 
the  localization  of  the  lesion  was  found  in  the  mesenteric  glands,  it  was 
clear  that  ingestion  of  the  bacilli  was  the  channel  of  entry,  and  this  was 
confirmed  by  the  fact  that  in  mesenteric  tuberculosis  bovine  bacilli 
were  often  found. 

But  we  have  seen  that  this  is  not  necessarily  the  case.  Entering 
via  the  digestive  tract,  the  bacilli  may  reach  the  tracheobronchial 
glands  with  as  much  ease  as  when  entering  via  the  respiratory  tract. 
Behring  and  Calmette  and  their  school  maintain,  in  fact,  that  all 
tuberculosis,  especially  in  children,  is  lymphogenic  and  hematogenic 
(see  p.  47). 

From  the  facts  presented  in  the  chapter  on  phthisiogenesis  it  is 
clear  that  tuberculosis  during  infancy  and  childhood  is  hematogenic, 
irrespective  of  the  portals  of  entry  of  the  bacilli.  A  study  of  the  rates 
of  mortality  during  the  various  ages  of  life  confirms  this  view.  As 
will  be  seen  from  the  accompanying  diagram  (Fig.  09),  pulmonary 
tuberculosis  is  a  frequent  cause  of  death  in  infants  under  two  years 


24 


1  Dis.  of  Infancy  and  Childhood,  p.  1027. 


370 


PULMONARY  TUBERCULOSIS  IN  CHILDREN 


TUBERCULOSIS  DURING  INFANCY  371 

of  age;  between  three  and  fourteen  years  of  age  comparatively  few 
succumb  to  this  form  of  the  disease,  only  after  fifteen  years  of  age  does 
it  become  very  frequent  and  remains  so  till  the  age  groups  above 
eighty  years.  We  know  from  clinical  experience  that,  when  occurring 
during  the  first  two  years  of  life,  pulmonary  tuberculosis  is  invariably 
an  acute  disease,  and  the  chronic  type  is  unknown  at  this  age.  On  the 
other  hand,  all  other  forms  of  tuberculosis,  including  that  of  the  glands, 
bones,  joints,  serous  cavities,  especially  the  meninges,  and  the  intes- 
tines, in  short,  the  hematogenic  forms  of  tuberculosis,  cause  death 
most  frequently  during  the  first  four  years  of  life,  and  are  compara- 
tively uncommon  as  a  cause  of  death  after  the  fifth  year  of  life. 

It  is  thus  clear  that  ^cute  tuberculosis,  as  well  as  the  hematogenic 
forms  of  this  infection,  have  a  different  age  incidence  when  compared 
with  chronic  phthisis,  the  disease  which  creates  the  main  problem. 
Moreover,  as  was  already  shown,  during  the  years  when  most  of  the 
human  infections  take  place,  between  the  second  and  the  fourteenth, 
the  mortality  from  all  forms  of  tuberculosis  is  comparatively  low; 
even  hematogenic  tuberculosis  as  a  cause  of  death  maintains  the  same 
rate  throughout  the  rest  of  human  life.  It  also  shows  that  phthisis, 
which  is  a  common  cause  of  death  in  adults,  is  not  necessarily  pre- 
ceded by  infection  with  tubercle  bacilli  immediately  before  the  disease 
manifests  itself  by  symptoms.  It  shifts  the  problem  of  infection  from 
the  adult  to  the  child. 

Tuberculosis  during  Infancy. — We  have  shown  that  the  child  is 
born  free  from  tuberculosis,  and  that  infection,  if  it  takes  place  at 
all,  occurs  postpartum.  Virchow,  whose  autopsy  experience  was  as 
immense  as  that  of  any  physician,  stated  that  he  never  encountered 
a  case  of  fetal  tuberculosis.  Infection  in  an  infant  is  therefore  invari- 
ably primary  and  almost  always  followed  by  symptoms  of  disease. 
Indeed,  as  we  have  already  shown,  there  are  cases  on  record  in  which 
infants  brought  into  contact  with  a  consumptive  for  an  hour  or  so 
developed  tuberculous  disease  of  a  malignant  type.  When  the  infec- 
tion is  massive,  acute  general  tuberculosis  with  implication  of  the 
glandular  system,  and  often  of  the  lungs,  is  almost  invariably 
caused. 

The  infant's  organism  behaves  after  a  primary  infection  just  as  the 
very  susceptible  guinea-pig;  the  reason  being  that  there  is  a  primary 
infection  of  a  body  which  has  not  yet  been  immunized  by  a  previous 
mild  infection.  These  cases  are  mostly  seen  in  infants  who  live  with 
tuberculous  persons — the  father,  mother,  sister,  brother  or  nurse  being 
tuberculous  and,  in  handling  the  infant,  an  opportunity  is  afi^orded  to 
transmit  the  disease.  There  is  evidence  tending  to  show  that  in  some 
cases,  though  in  less  than  is  generally  supposed,  the  infection  is  derived 
from  bovine  bacilli  through  milk  from  tuberculous  cows. 

In  many  cases  no  exciting  cause,  except  the  source  of  infection, 
can  be  traced.  In  others  some  acute  endemic  disease  of  infancy  is 
found  to  have  produced  a  state  of  allergy.    This  is  especially  true  of 


372  PULMONARY   TUBERCULOSIS  IN  CHILDREN 

measles  and  whooping-cough,  but  any  of  the  other  contagious  diseases 
of  infancy  may  reduce  the  vitality  and  resisting  powers  of  the  infant 
and  infection  is  then  followed  by  the  characteristic  acute  form  of 
tuberculosis. 

Symptoms.— The  symptoms  depend  on  the  mode  of  onset  and  on 
the  parts  of  the  body  which  bear  the  brunt  of  the  infection.  In  those 
in  whom  tuberculosis  follows  in  the  wake  of  another  disease,  like 


Fig.  70. — A  primary  cheesy  focus  the  size  of  a  lentil  in  a  bronchus  of  the  left  lower 
lobe  with  miliary  and  conglomerate  tubercles  of  the  regional  peripheral  atelectatic  lung. 
Caseation  of  the  bronchopulmonary  and  lower  tracheobronchial  glands  in  the  region 
of  the  right  lower  lobe.     The  glands  on  the  left  side  are  free.     (Anton  Ghon.) 

whooping  cough,  measles,  etc.,  there  are  usually  symptoms  of  broncho- 
pneumonia or  meningitis,  which  carry  off  the  patient  within  a  few  days, 
a  week  or  two.  In  addition  to  the  symptoms  and  signs  of  broncho- 
pneumonia, there  is  often  found  enlargement  of  the  spleen  and  liver 
and  swelling  of  the  superficial  glands,  the  cervical,  axillary,  inguinal, 
etc.  This  form  of  acute  tuberculosis  is  best  seen  in  cases  of  tubercu- 
lous disease  engendered  by  inoculation,  as  in  infection  of  the  wound 


TUBERCULOSIS  DURING  INFANCY  373 

after  ritual  circumcision.  Arkick  and  Wincouroff/  and  Holt-  have 
recently  described  such  cases  in  detail. 

In  those  in  whom  the  disease  is  slower  in  development,  athrepsia  is 
seen.  It  is  noted  that  the  child  does  not  thrive  despite  the  fact  that  its 
nourishment  leaves  little  or  nothing  to  be  desired  and  the  gastro- 
intestinal functions  are  fairly  normal.  There  may  be  no  fever  at  all. 
Still  the  emaciation  proceeds  frightfully.  In  some  cases  the  emacia- 
tion consumes  nearly  all  the  subcutaneous  adipose  tissue  and  the 
thin,  pale  skin  is  stretched  over  the  atrophied  bones.  These  infants 
usually  have  long  hair  on  the  back  between  the  shoulder  blades  and 
on  the  extremities;  their  eyes  are  sunken  and  the  eyelashes  are 
unusually  long.  Finally  the  temperature  begins  to  rise  and  may 
reach  very  high,  and  they  succumb  to  symptoms  of  septicemia  or 
meningitis. 

Examination  of  the  chest  may  not  show  any  changes,  while  in  some 
we  may  find  areas  of  defective  resonance,  bronchial  breathing  or  rales. 
In  infants  limited  and  circumscribed  lesions  are  very  difficult  of  locali- 
zation because  we  have  no  assistance  on  their  part  while  exploring  the 
chest. 

Cough  may  be  absent  altogether,  but  in  some  cases  we  meet  with  a 
peculiar  cough  caused  by  pressure  of  enlarged  glands  on  the  bronchi, 
or  on  the  nerves  passing  through  the  chest.  Eustace  Smith^  first 
described  this  cough  as  spasmodic,  occurring  irregularly  in  paroxysms 
like  those  of  pertussis,  lasting  only  a  short  time  and  ending  sometimes, 
though  rarely,  in  a  crowing  inspiration.  This  cough  has  since  been 
differently  described  by  various  authors.  Schick*  describes  a  respira- 
atory  crow  or  stridor  resembling  the  sound  heard  in  asthma  and  in 
capillary  bronchitis.  It  can,  however,  be  distinguished  from  the  latter 
by  the  fact  that  in  asthma  the  cough  is  paroxysmal  while  the  stridor 
in  bronchial  adenopathy  in  infancy  is  continuous,  lasting  without 
change  for  weeks  and  months.  The  French  have  described  it  as  Mix 
coqueluchoide,  and  Strieker  compares  it  with  the  bark  of  a  hoarse 
puppy. 

In  most  of  these  slow  cases  the  cachexia  progresses  till  finally  the 
child  succumbs  to  some  intercurrent  disease  or  to  tuberculous 
bronchopneumonia.  On  rare  occasions  a  softened  gland  ruptures 
into  a  bronchus  causing  aspiration  pneumonia.  A  relatively  large 
proportion  end  up  with  tuberculous  meningitis.  Investigations  made 
by  the  writer^  in  children  under  six  years  of  age  living  a  tuberculous 
milieu  in  New  York  City  have  shown  that  16  per  cent,  succumb  to 
meningitis,  as  against  only  2.6  per  cent,  among  the  general  population. 

Other  infants  may  be  anemic  and  underfed  for  months.    They  do 


1  Beitr.  z.  klin.  d.  Tuberkulose,  1912,  xxii,  341. 

2  Jour.  Amer.  Med.  Assn.,  1913,  Ixi,  99. 

5  Wasting  Diseases  of  Infants  and  Children,  London,  1878. 
"  Verhandl.  d.  Ges.  f.  Kinderheilkunde,  xxvi,  1909,  121. 
5  Archives  of  Pediatrics,  1914,  xxxi,  197. 


374  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

not  thrive  in  spite  of  all  efforts  to  improve  tlieir  nutrition.  Finally, 
the  marasmus  assumes  an  acute  character,  the  fever  rises  and  they 
succumb  to  exhaustion  or  more  commonly  to  some  intercurrent  disease. 

Diagnosis. — It  is  clear  that  the  diagnosis  of  tuberculosis  in  infancy 
is  not  an  easy  matter.  Hamburger's^  advice  should  be  followed  by 
all  who  have  infants  under  their  care:  Think  of  tuberculosis  in  every 
case  in  which  no  other  diagnosis  can  be  made.  This  dictum  is  shared  by 
nearly  all  other  pediatrists  who  have  given  thought  to  the  problem. 
Tubercle  bacilli  cannot  be  discovered  because  infants  do  not  expec- 
torate. Holt  has,  however,  often  found  them  by  swabbing  the  throat 
with  a  pledget  of  cotton.  A  positive  tuberculin  (von  Pirquet)  reaction 
in  an  infant  under  one  year  is  sufficient  to  clinch  the  diagnosis.  Un- 
fortunately during  the  course  of  measles,  or  whooping-cough  and  in 
tuberculous  meningitis,  the  tuberculin  reaction  is  apt  to  be  negative, 
despite  the  presence  of  tuberculous  infection. 

Prognosis. — The  prognosis  of  tuberculosis  in  infancy  is  very  gloomy. 
In  fact  it  may  be  stated  that  the  younger  the  infant  the  more  unfav- 
orable the  prognosis.  During  the  first  three  months  of  life  hardly 
any  survive  infection;  the  vast  majority  of  those  infected  during  the 
second  three  months  of  life  succumb  to  the  disease  or  to  some  inter- 
current infection;  the  outlook  for  infants  between  six  and  eighteen 
months  is  very  unfavorable  when  infected  with  tuberculosis. 

In  this  gloomy  prognosis  nearly  all  authorities  agree:  Holt^  holds 
that  the  outlook  for  a  young  child  with  general  or  pulmonary  tuber- 
culosis is  always  bad;  Schlossmann^  says  that  he  does  not  know  of  a 
single  case  in  an  infant  which  resulted  in  recovery;  von  Pirquet 
maintains  that  90  per  cent,  of  infants  infected  during  the  first  year  of 
life  perish;  Louis  Guinon'*  says  that  before  the  fourth  year  of  life 
tuberculosis  is  always  fatal;  and  Monti^  says  that  he  never  saw  a  case 
of  tuberculosis  in  an  infant  under  two  years  recover. 

It  appears  to  be  the  consensus  of  opinion  of  most  pediatrists  that  all 
tubercles  during  the  first  two  or  three  years  of  life  are  active,  that  the 
lungs  show  no  tendency  to  limitation  of  the  disease  and  that  there  are 
no  reparative  processes  to  be  noted  when  examining  the  lungs  of 
children  who  succumbed  to  tuberculosis.  No  cicatrization  or  calci- 
fication is  to  be  observed. 

The  corollary  has  been  drawn  that  all  infants  showing  signs  of 
infection  with  tubercle  bacilli — a  positive  von  Pirquet  reaction — are 
doomed.  The  writer  cannot  agree  with  this.  We  have  followed 
infants  showing  positive  von  Pirquet  reactions  during  the  first  three 
months  of  life  growing  into  healthy  children.  It  appears  that  the 
dangers  of  developing  active  tuberculous  disease,  and  the  acuteness  of 

1  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  d.  Tuberkulose,  Leipzig,  1915,  v,  6. 

^  Dis.  of  Infancy  and  Childhood,  5th  edition,  p.  1004. 

^  Pfandler  and  Schlossmann's  Diseases  of  Children,  Philadelphia,  1912,  ii,  632. 

^  La  prat,  des  mal.  des  enf.,  Paris,  1911,  iv,  479. 

^  Ueber  Tuberkulose.  Kinderhcilkunde  iu  Einzeldarstellungen,  1901. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  375 

the  process  engendered,  are  in  inverse  ratio  to  the  age  at  which  the 
infection  takes  place.  The  younger  the  infant  the  more  unfavorable 
the  prognosis.  But  even  among  very  young  infants  cicatrization  and 
calcification  of  the  lesion  may  occur.  In  another  place  I  have  col- 
lected evidence  showing  that  such  healed  lesions  were  found  at 
autopsies  made  on  infants  who  died  from  other  causes. 


TUBERCXJLOSIS   DURING   EARLY   CHILDHOOD. 

Significance  of  Tuberculosis  during  Childhood. — In  our  study  of  the 
epidemiology  of  tuberculosis  we  have  seen  that  the  child  is  born  free 
from  tuberculosis  but  that  soon  after  birth,  on  coming  into  contact  with 
tuberculous  individuals  or  their  discharges,  or  consuming  milk  from 
tuberculous  animals,  it  is  infected  with  tubercle  bacilli.  We  have 
also  shown  that  during  the  first  year  of  life  relatively  few — between 
5  and  10  per  cent. — are  infected  with  tubercle  bacilli.  During  the 
second  year  more  are  infected,  and  the  number  of  infections  keeps  on 
growing  so  that  at  the  age  of  fifteen  over  90  per  cent,  show  unmistak- 
able signs  of  harboring  tubercle  bacilli  in  the  body.  A  study  of  the 
mortality  from  tuberculosis  according  to  age  groups  has  shown  that 
the  mortality  from  this  disease  is  very  high  during  the  first  two  years 
of  life.  Considering  the  malignant  clinical  forms  of  the  disease  which 
have  been  described  above,  the  reason  is  clear.  But  beginning  with 
the  third  year  the  number  that  succumbs  to  this  disease  is  very  small 
and  this  low  mortality  keeps  on  till  the  fifteenth  year,  when  there  is 
another  increase  which  keeps  on  rising,  so  that  from  the  twentieth 
year  onward  the  maximum  has  been  reached  which  keeps  up  till  far- 
advanced  age. 

It  is  thus  clear  that  during  the  years  when  most  infections  with 
tubercle  bacilli  take  place,  the  mortality  is  at  its  lowest.  It  is  also  clear 
that  if  infection  is  to  take  place,  which  we  have  shown  to  be  inevitable 
for  those  living  in  large  industrial  towns  and  coming  into  contact  with 
many  people,  it  is  best  that  it  should  occur  during  childhood.  Appar- 
ently, during  this  age  period  death  due  to  tuberculosis  is  exceptional. 
This  point  will  be  discussed  again  when  speaking  of  the  prophylaxis 
of  tuberculosis. 

Infection  and  Morbidity. — ^We  must  again  emphasize  the  difference 
between  infection  with  tubercle  bacilli  and  disease  due  to  this  micro- 
organism. It  appears  that  the  vast  majority  of  children  infected  with 
tubercle  bacilli  do  not  show  any  clinical  manifestation  of  disease, 
otherwise  over  50  per  cent,  of  children  in  large  cities  would  be  sick  and 
in  need  of  careful  treatment;  at  the  age  of  ten  over  75  per  cent,  would 
be  sick  and  in  need  of  dietetic,  specific,  institutional  or  climatic  treat- 
ment. Scientific  tests  prove  conclusively  that  the  vast  majority  of 
children  have  been  infected,  and  but  few  show  clinical  manifestations 
of  disease;   hence  the  bulk  of  infections  at  that  age  cause  no  disease, 


376  PULMONARY   TUBERCULOSIS  IN  CHILDREN 

and  may  be  disregarded  by  the  clinician.  Some,  however,  do  show 
ch'nical  manifestations  of  disease. 

Tuberculous  Tracheobronchial  Adenopathy. — Exchiding  tuberculosis 
of  the  bones  and  joints  and  the  meninges,  the  bvdk  of  the  tuberculous 
morbidity  is  caused  by  tuberculosis  of  the  glands,  especially  the  cervi- 
cal and  the  intrathoracic.  In  most  of  the  children  having  enlarged 
tuberculous  glands  the  symptoms  are  negligible,  or  there  are  no  clinical 
manifestations  at  all.  Thus  we  often  discover  enlarged  glands  on  the 
neck  or  in  the  thorax  of  children  who  are  in  an  excellent  condition  of 
health.  In  some  we  find  the  glands  enlarged  for  some  time,  then  there 
is  recession,  the  swelling  goes  down  or  disappears,  while  the  children 
kept  up  their  activities  at  school,  and  were  none  the  worse  for  the 
experience.  In  others  the  appearance  of  the  glands  is  concurrent 
with  the  occurrence  of  some  disease,  like  measles,  scarlet  fever,  whoop- 
ing-cough, etc.;  they  remain  enlarged  during  convalescence,  but  after 
complete  recovery  they  recede  or  disappear  permanently^,  or  may 
return  when  some  other  exciting  cause  is  again  operative.  We  may 
thus  see  in  many  children  a  tendency  to  enlargement  of  the  glands 
whenever  an  exciting  cause  is  operative,  but  the  innate  forces  of 
resistance  are  at  work  and  recovery  takes  place  in  a  short  time,  spon- 
taneously or  after  some  treatment  has  been  instituted.  This  class  of 
children  needs  no  special  treatment  beyond  life  in  healthy  surroundings 
and  good  nourislnnent.  • 

Symptoms  of  Glandular  Tuberculosis  in  Children. — In  others  the 
appearance  of  glandular  tuberculosis  is  accompanied,  often  preceded, 
by  symptoms  which  are  troublesome  and  need  careful  study  for  their 
recognition. 

Of  these  symptoms  the  following  are  the  most  important :  Emacia- 
tion, fever,  nightsweats,   anemia,  anorexia,  etc. 

Emaciation. — A  healthy  child  gains  in  weight  constantly,  and  if  it 
is  regularly  weighed,  say  every  month,  it  will  be  found  that  the  scale 
registers  more  than  at  the  preceding  weighing.  While  in  normal 
adults  a  lack  in  this  direction  is  not  necessarily  an  indication  of  disease, 
because  they  may  have  reached  their  normal  standard,  or  even  exceeded 
it,  with  children  conditions  are  different.  Commensurate  with  their 
gain  in  height,  there  must  be  a  gain  in  weight  in  children  of  school 
age.  It  is  known  as  the  normal  increment  in  the  size  of  the  body. 
When  a  child  does  not  gain  in  weight  it  is,  with  few  exceptions,  an 
indication  of  disease. 

To  ascertain  this  gain  in  weight  various  tables  have  been  prepared 
by  anthropometristS  and  reproduced  in  many  text-books  on  pediatrics. 
But  I  want  to  warn  the  practitioner  against  comparing  the  weight  of 
a  child  under  his  care  with  that  given  in  any  of  these  tables.  To  begin 
with,  the  weight  given  in  the  table  for  each  age  is  an  average  of  a  large 
number  of  children,  and  averages  permit  variations  that  are  normal. 
The  weight  of  the  child  depends  solely  on  its  height,  and  there  are 
perfectly  healthy  children  and  adults  who  are  short  of  stature. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  377 

What  the  physician  should  look  for  is  a  steady  gain.  If  this  is  not 
found,  it  is  clear  that  the  child  is  sick.  At  any  rate,  it  demands  an 
explanation.  In  many  cases  it  may  be  because  of  some  intercurrent 
non-tuberculous  disease.  But  it  should  be  found  and  treated.  When 
we  find  that  a  child  is  not  gaining  in  weight  for  several  months,  it  is 
equivalent  to  a  steady  loss  in  an  adult.  If  there  is  no  morbid  condition 
to  account  for  it,  tuberculosis  may  safely  be  suspected  as  the  cause. 
A  careful  physical  examination  will,  in  the  majority  of  cases,  reveal 
enlarged  intrathoracic  glands. 

An  exception  is  to  be  mentioned.  Infants  may  be  suffering  as  a 
result  of  tuberculous  infection  and  show^  no  signs  of  emaciation  for 
a  long  time.  This  is  evident  from  the  fact  that  tuberculous  menin- 
gitis or  bronchopneumonia  often  attacks  well-nourished  infants.  Infan- 
tile tuberculosis,  unless  the  gastro-intestinal  tract  is  affected,  does 
not  often  lead  to  cachexia. 

With  the  emaciation  there  is  often  to  be  observed  anemia,  mani- 
festing itself  in  marked  pallor  of  the  skin  and  mucous  membranes, 
though  an  examination  of  the  blood  may  not  disclose  any  definite 
changes  in  its  cytology. 

Fever. — ^Whenever  tuberculous  glands  cause  trouble  there  is  a  rise  in 
temperature.  Hamburger's  conception  of  tuberculous  disease  supplies 
the  theoretical  basis  for  the  fever  in  these  cases.  He  looks  upon  all 
clinical  exacerbations  of  tuberculosis  as  spontaneous  tuberculin  reac- 
tions due  to  to  a  sudden  flooding  of  the  body  juices  with  tuberculin, 
producing  the  same  symptoms  as  we  produce  artificially  by  injecting 
tuberculin. 

The  healthy  child's  temperature  oscillates  between  98.8°  and  99.8° 
F.  Whenever  it  rises  above  these  limits,  it  is  to  be  considered  patho- 
logical and  an  explanation  is  to  be  sought.  If  no  cause  can  be  found 
for  elevation  of  temperature,  which  is  observed  persistently  for  several 
weeks,  tuberculosis  is  to  be  thought  of.  In  most  cases  it  will  be  found 
that  in  addition  to  the  thermometrical  findings  there  are  also  symp- 
toms of  hyperthermia,  such  as  anorexia,  languor,  etc.  The  child  may 
feel  refreshed  and  lively  during  the  morning  hours,  but  late  in  the 
afternoon  it  is  flushed,  tired,  and  seeks  rest. 

In  evaluating  thermometrical  findings  it  must  always  be  remem- 
bered that  the  fluctuations  in  the  temperature  are  much  more  pro- 
nounced in  children  than  in  adults.  Thus  among  children  in  Chicago, 
Th.  Sachs^  found  that  the  morning  temperature  fluctuated  between 
98.4°  and  100.4°  F.  and  the  afternoon  temperature  between  97.4°  and 
100.5°  F.  E.  Wynne^  found  that  among  1000  children  261  had  tem- 
peratures of  99°  F.  or  over,  and  of  these,  112  presented  no  obvious 
pathological  condition  to  account  for  the  hyperthermia.  Mary  E. 
Williams^  found  among  1000  school  children  between  the  ages  of 

1  Sixth  Intern.  Congr.  on  Tuberc,  1908,  ii,  479. 

2  PubHc  Health,  1913,  xxvi,  136. 

3  Lancet,  1912,  i,  1192. 


378  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

twelve  and  fourteen  years  no  less  than  55.5  per  cent,  had  temperatures 
of  99.6°  F.  and  higher. 

There  are  two  reasons  to  account  for  the  oscillations  of  the  tem- 
perature in  children.  The  heat  centre  is  more  apt  to  be  disturbed  by 
slight  factors  than  in  adults,  as  is  shown  by  the  fact  that  nearly  all 
pathological  conditions  produce  higher  fever  in  them  than  in  adults. 
Then,  there  are  so  many  subacute  or  chronic  conditions  which  produce 
mild  fever  in  children,  that  it  would  be  wrong  to  base  a  diagnosis  of 
tuberculosis  on  thermometrical  findings  alone.  But  when  the  tem- 
perature is  found  elevated  persistently  for  several  weeks  in  a  child,  and 
other  symptoms  of  tuberculosis  are  present,  while  no  other  cause 
can  be  discovered,  the  patient  is  to  be  kept  under  careful  observation. 
A  difference  of  more  than  1.5°  F.  between  the  minimum  and  maximum 
temperature  of  the  day,  when  persistent,  points  to  tuberculosis,  when 
no  other  cause  can  be  found. 

Nightsweats. — As  a  symptom  of  tuberculosis  in  children  night- 
sweats  have  not  the  same  significance  as  in  adults.  Many  non-tuber- 
culous children  sweat  during  the  night.  In  a  study  of  the  physiological 
phenomena  of  sleep  in  children,  Czerny^  found  that  the  intensity  of 
evaporation  from  the  skin  goes  hand-in-hand  with  the  depth  of  the 
sleep.  At  the  time  when  sleep  is  most  intense,  at  its  maximum,  the 
skin  is  warm  and  moist,  and  usually  profuse  perspiration  on  the  face  is 
noted.     This  is  not  to  be  considered  pathological. 

To  be  of  diagnostic  significance,  nightsweats  in  children  must  appear 
during  the  second  half  of  the  night  and  be  so  profuse  as  to  soak 
through  the  bedclothes.  Even  in  such  cases  they  may  not  be  pathogno- 
monic of  tuberculosis;  the  possibility  must  always  be  borne  in  mind 
that  they  may  be  of  nervous  origin,  especially  in  older  children.  At 
any  rate,  nightsweats  are  often  absent  in  tracheobronchial  adenopathy, 
though  with  each  exacerbation  of  the  symptoms  of  activity,  they  are 
to  be  observed. 

In  tuberculous  bronchopneumonia  in  children  nightsweats  are  the 
rule,  but  in  non-tuberculous  cases  they  are  often  a  prominent  and 
annoying  symptom. 

Cough. — Cough  is  another  symptom  of  active  tuberculosis  in  children. 
Hamburger  says  that  it  is  never  absent  in  active,  incipient  cases,  and 
when  a  cough  lasts  more  than  a  week  the  possibility  of  tuberculosis 
should  be  considered  and  a  thorough  search  for  other  symptoms  and 
signs  of  the  disease  should  be  inaugurated.  In  advanced  stages  of 
the  disease  cough  may  be  lacking,  especially  when  there  is  an  arrest 
in  the  progress  of  the  disease,  which  is  not  infrequently  the  case  in 
children  between  eight  and  fourteen  years  of  age.  But  even  in  these 
cases  we  meet  with  frequent  exacerbations  of  the  disease  when  the 
child  coughs  more  or  less.  According  to  Schlossmann,  Holt  and  others, 
cough  may  be  entirely  absent  in  infants  with  active  disease. 

1  Jahrb.  f.  Kinderheilk.,  1892,  xxxiii,  22. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD 


379 


We  must,  however,  emphasize  that  in  children  over  three  years  of 
age  cough  is  onl}^  of  significance  as  a  symptom  of  active  tuberculosis 
when  other  symptoms  are  present,  especially  emaciation.  When 
a  child  thrives,  despite  a  chronic  cough,  it  will  be  found  that  there  is 
another  cause,  especially  chronic  or  subacute  catarrhs  of  the  nose  and 


Fig.  71. — Diagram  showing  greater  number  of  glands  located  on  the  right  side. 

throat,  particularly  during  the  winter  months.  Asthma  also  is  often 
a  cause,  and  so  is  chronic  bronchitis,  though  we  must  be  careful  when 
finding  unilateral  bronchitis,  which  is  almost  invariably  tuberculous. 

The  paroxysmal  and  the  brassy  cough  of  infants,  as  well  as  the 
expiratory  stridor  of  infants  have  already  been  described. 

Children  presenting  any  or  all  of  these  symptoms — emaciation,  fever. 


380 


PULMONARY  TUBERCULOSIS  IN  CHILDREl^ 


nightsweats,  cough,  etc. — require  a  careful  physical  examination  and 
if  these  symptoms  are  due  to  active  tuberculosis,  we  almost  invariably 
find  local  tuberculous  changes — that  the  glands  are  affected — except  in 
those  over  eight  years  of  age,  among  whom  localized  pulmonary 
tuberculosis  of  the  same  character  as  in  adults  may  be  found. 


Fig.  72. 


-Tuberculosis  of  cervical  and  axillary  lymph  nodes  in  an  eight-year-old  bov. 
(Carr.) 


Cervical  Adenopathy. — Among  the  glands  most  frequently  affected 
in  active  tuberculosis  in  childhood  the  most  important  are  the  cervical 
and  the  tracheobronchial.  The  former  group  is  easily  examined  because 
when  enlarged,  we  can  see  and  palpate  them  and  ascertain  their 
condition. 

If  we  should  take  enlarged  cervical  glands  as  an  indication  of  active 
tuberculosis  in  children,  we  would  find  very  few  raised  under  adverse 
hygienic  and  economic  conditions  who  are  free  from  the  disease.    Thus, 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  381 

among  692  children  of  tuberculous  parentage  examined  by  the  author, 
469,  or  67.8  per  cent.,  had  swollen  cervical  glands.  A  careful  examina- 
tion of  children  attending  dispensaries  shows  that  between  50  and 
75  per  cent,  have  palpable  cervical  glands.  Most  of  them  are  due  to 
carious  teeth,  hypertrophied  tonsils,  stomatitis,  eczema  or  pediculi  of 
the  scalp,  etc.  That  they  are  no  indication  that  the  intrathoracic 
glands  are  also  swollen  may  be  concluded  when  we  bear  in  mind  that 
anatomically  the  two  groups  have  no  direct  connection,  as  has  already 
been  shown  (p.  47). 

Some  distinction  may,  however,  be  made  between  enlarged  cervical 
glands  due  to  tuberculosis  and  those  due  to  other  causes.  When  the 
tumors  in  the  neck  are  very  large  and  persistent,  showing  little  ten- 
dency to  caseation  and  suppuration,  they  are  almost  invariably  tuber- 
culous. Of  greater  importance  is  enlargement  of  the  supraclavicular 
glands,  which  drain  the  parietal  pleura,  especially  when  found  unilat- 
erally. This  speaks  for  tuberculosis  of  the  costal  pleura,  as  has  been 
pointed  out  by  Hamburger.  Ranke^  has  pointed  out  another  charac- 
teristic of  tuberculous  cervical  glands.  They  are  apt  to  swell  up  at 
irregular  intervals  and  retrogress  again  after  remaining  large  for  a  few 
days  or  weeks,  and  each  time  the  swelling  increases  there  is  an  increase 
in  the  intensity  of  the  constitutional  symptoms.  During  the  retro- 
gression they  become  smaller,  harder,  lose  their  roundish  contour 
and  become  fixed  to  the  surrounding  tissues.  But  while  this  sign  is 
undoubtedly  of  value,  it  has  failed  me  in  several  cases. 

Physical  Signs  of  Tracheobronchial  Adenopathy. — The  best  that 
can  be  said  about  the  physical  diagnosis  of  tracheobronchial  adenopathy 
is,  that  it  is  very  indefinite;  at  any  rate,  all  the  criteria  taken  for 
proof  of  the  existence  of  enlarged  glands  within  the  thoracic  cavity  do 
not  enlighten  us  whether  the  process  is  active  and  demands  active 
treatment,  or  is  merely  an  innocuous  enlargement  of  the  glands  of  no 
clinical  importance,  as  it  actually  is  in  the  vast  majority  of  cases.  Judg- 
ing by  the  anatomical  relations  of  these  glands,  it  is  clear  that  they 
must  attain  some  size  before  they  become  discoverable  by  percussion 
and  auscultation  of  the  chest.  But  that  they  often  do  attain  large 
dimensions  may  be  assumed  when  we  consider  the  size  attained  by  the 
cervical  glands  at  times. 

This  group  of  glands  includes  those  located  around  the  trachea  and 
bronchi,  mainly  in  front  of  the  bifurcation  of  the  trachea.  Pathologic- 
ally, it  has  been  found  that  those  around  the  right  bronchus  are  liable 
to  attain  very  large  dimensions  and  produce  symptoms  and  signs  of 
the  disease.  From  the  practical  standpoint,  in  addition  to  the  anterior 
and  posterior  mediastinal  glands,  there  are  three  groups  of  glands 
which  may  become  swollen  because  of  tuberculous  infection:  At  the 
bifurcation  of  the  trachea  we  have  the  tracheobru7ichial  hpnyh  nodes; 
along  the  main  bronchi  there  are  the  hronchial  lym/ph  nodes;    and  at 

1  Munch,  med.  Wchnschr.,  1914,  Ixi,  2099. 


382 


PULMONARY  TUBERCULOSIS  IN  CHILDREN 


'J'        ^ 


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'1 

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^- 

Figs.  73  and  74. — Composite  drawings  showing  the  relationship  of  the  bronchial 
glands  to  the  thoracic  wall  in  the  adult.  The  glands  are  according  to  Sukiennikow,  and 
the  trachea  and  bronchi  are  after  Blake  (Amer.  Jour.  Med.  Sci.,  1899,  cxvii,  320).  In 
the  child  the  trachea  bifurcates  at  about  the  level  of  the  intervertebral  disk  between 
the  fourth  and  fifth  thoracic  vertebrae,  which  corresponds  nearly  to  the  tip  of  the  fourth 
thoracic  spine.  This  is  about  opposite  the  articulation  of  the  third  costal  cartilage 
anteriorly.     (Stoll.) 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  383 

the  hilus  of  the  lungs  there  are  the  pulmonary  lyiniDh  nodes,  which  also 
surround  the  bronchi,  and  communicate  though  lymph  spaces  with 
the  parenchyma.  In  fact,  all  these  glands  receive  their  lymph  from 
the  pulmonary  tissue  and  the  bronchi.  Considering  their  anatomical 
relations  it  is  clear  that  when  enlarged,  they  may  exert  pressure  upon 
the  bronchi  and  trachea,  as  well  as  on  the  nerves  and  bloodvessels 
passing  through  the  chest.  They  may  produce  symptoms  because  of 
pressure  exerted  on  the  vagus  and  recurrent  laryngeal  nerves  and  the 
superior  vena  cava.  They  may  even  press  upon  the  phrenic  nerve, 
the  arch  of  the  aorta,  innominate  veins,  etc.  But  this  is  exceptional 
despite  the  fact  that  text-books  give  so  many  signs  revealing  pressure 
on  the  various  structures.  The  anatomical  relations  of  these  glands 
are  shown  vividly  in  the  accompanying  illustration  (Figs.  73  and  74) 
from  Stoll,^  based  on  Sukiennikow's^  anatomical  researches. 

Inspection. — On  inspection  the  thorax  is  often  found  deformed  in 
those  who  have  had  enlarged  glands;  indeed,  some  of  the  deformities 
produced  by  the  intrathoracic  glands  are  difficult  to  differentiate  from 
the  changes  produced  by  early  rickets.  In  some  cases  we  find  the 
typical  phthisical  chest,  the  habitus  phthisicus — a  long,  narrow  chest 
with  the  ribs  slanting  downward  at  an  acute  angle,  and  the  inter- 
costal spaces  narrow.  Children  with  such  chests  have  passed  through 
several  attacks  of  glandular  enlargement  and  may,  at  the  time 
of  examination,  be  in  fair  health.  In  many  we  see  what  Stoll  calls  the 
"hilus  dimple."  If  the  breath  is  held  at  the  end  of  inspiration  there  is 
seen  an  apparent  retraction  on  one  or  both  sides  in  the  second  inter- 
space. Owing  to  lack  of  expansion  of  one  apex,  the  chest  wall  lags  with 
inspiration.  In  old  cases  this  "dimple"  may  remain  permanently 
owing  to  permanent  pleural  adhesions  or  cicatrization  of  the  peri- 
bronchial tissues  at  the  hilus  (Figs.  75  and  76). 

This  phthisical  chest,  which  some  authors  consider  predisposing  to 
phthisis,  is  in  fact  proof  that  the  patient  has  been  tuberculous  for  a 
long  time  and  in  children  it  is  proof  that  the  thoracic  glands  have 
been  enlarged.  In  our  investigations  of  the  form  of  the  chest  in  children 
of  tuberculous  parentage,  we  found  that  at  birth  the  chest  is  almost 
invariably  normal,  and  only  when  tubercle  affects  the  intrathoracic 
viscera  are  changes  in  its  form  produced.  In  some  cases  unilateral 
bulging  of  the  chest  wall  is  noted,  especially  the  first  two  interspaces 
near  the  sternum. 

Enlarged  veins  are  often  visible  on  a  chest  containing  enlarged 
glands.  They  are  usually  seen  on  the  upper  part  of  the  thorax,  mostly 
bilateral  though  not  symmetrical,  and  at  times  unilateral.  In  my  own 
cases,  37.5  per  cent,  of  children  with  tracheobronchial  adenopathy  had 
enlarged  and  visible  veins  on  the  thorax,  and  of  these,  three-fourths 
were  unilateral.    Of  those  in  whom  the  diagnosis  of  latent  tuberculosis 

1  Amer.  Jour.  Med.  Sci.,  1911,  cxli,  83;  Ibid.,  1914,  cxlviii,  369;  Anier.  Jour.  Dis. 
Children,  1912,  iv,  333. 

2  Berl.  klin.  Wchnschr.,  1905,  xi,  316,  347,  369. 


384 


PULMONARY   TUBERCULOSIS  IN  CHILDREN 


was  justified,  or  in  whom  it  was  strongly  suspected,  25  per  cent,  showed 
this  sign,  while  among  the  manifestly  healthy  only  about  1  per  cent, 
had  enlarged  veins  on  the  thorax.  Stoll  found  enlarged  and  visible 
veins  on  the  thorax  in  92  out  of  173  cases;  of  these  50  per  cent,  were 
tuberculous. 

It  thus  appears  that  this  is  a  fair  sign  of  compression  of  the  main 
trunks  of  the  intrathoracic  veins  by  enlarged  glands  or  adherent 
pleura.  My  general  experience,  however,  urges  me  against  hasty 
diagnosis  based  on  this  sign  alone.  It  is  met  with  in  many  healthy 
children,  especially  such  as  have  a  delicate  and  transparent  skin  and  also 
in  anemia.  In  adults,  it  is  often  seen  in  women  during  lactation, 
when  it  may  be  unilateral,  and  in  persons  suffering  from  non-tuber- 


FiG.  75  Fig.  76 

Figs.  75  and  76.— The  "hilus  dimple."     (Stoll.) 

culous  affections  of  the  bronchi,  lungs  and  pleura,  especially  chronic 
bronchitis,  asthma,  and  pulmonary  emphysema  (see  p.  244). 

Percussion. — A  great  deal  has  been  written  about  percussion  as  an 
aid  to  the  diagnosis  of  tracheobronchial  adenopathy.  But  as  a  matter 
of  fact  there  are  many  children  with  undoubted  enlargement  of  these 
glands  in  whom  the  percussion  note  elicited  over  every  part  of  the  chest 
is  practically  normal.  When  we  consider  the  topographical  position 
of  the  bifurcation  of  the  trachea,  it  is  clear  that  the  glands  must  become 
very  large  to  produce  dulness  anteriorly  or  posteriorly  over  the  surface 
of  the  chest.     The  various  special  methods  like  Koranyi's^  vertebral 


1  Ztschr.  f.  kliu.  Med.,  1906,  Ix,  295. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  385 

percussion,  which  has  been  elaborated  in  this  country  by  John  C. 
Da  Costa,'  do  not  give  satisfaction.  In  many  cases,  however,  there  is 
found  paravertebral  dulness  on  light  percussion.  The  areas  that  may 
be  found  affected  correspond  to  the  hilus — the  interscapular  space, 
especially  the  right,  and  anteriorly  in  the  upper  two  interspaces 
near  the  sternum.  To  elicit  this,  very  light  percussion  is  necessary 
because  of  the  thinness  and  resilience  of  the  thoracic  walls  in  the  child. 
It  may  be  found  when  the  glands  are  not  very  much  enlarged;  then  it 
is  due  to  engorgement  of  the  bloodvessels  and  lymphatics  which  exists 
in  the  region  of  the  hilus  during  the  acute  stage.  It  is  the  collateral 
inflammation  described  by  Tendeloo.^ 

This  defective  resonance  is  only  rarely  bilateral.  Anteriorly  it  must 
be  differentiated  from  the  dulness  due  to  an  enlarged  thymus.  The 
latter  is  usually  beneath  the  sternum,  while  in  bronchial  adenopathy 
the  dulness  is  mainly  at  the  side  of  that  bone,  mostly  to  the  right. 
We  must  mention  that  there  is  normally  an  oval  area  of  dulness  between 
the  first  and  fifth  thoracic  vertebrae,  extending  an  inch  to  two  outward 
on  each  side  of  the  spine  to  which  William  Ewart^  has  called  attention. 
But  in  cases  of  glandular  enlargement  it  is  usually  unilateral — one 
interscapular  space  is  dull.  I  have  seen  a  few  cases  in  which  enlarged 
thoracic  glands  produced  dulness  all  over  one  side  of  the  chest.  Another 
point  is  that  this  dulness,  to  be  indicative  of  adenopathy,  must  be 
permanent,  found  during  several  examinations.  As  has  been  pointed 
out  by  Grancher  and  J.  E.  H.  Sawyer,*  in  debilitated  and  rachitic 
children  there  are  observed  transient  areas  of  dulness  due  to  a  bronchus 
being  plugged  with  secretions  and  the  resulting  atelectasis  of  the  air 
vesicles  it  supplies. 

Auscultation. — In  my  experience  auscultation  has  been  of  more 
service  in  attempting  to  diagnosticate  intrathoracic  glands.  In 
children  the  breath  sounds  are  louder  and  somewhat  harsher  than  in 
the  adult — puerile.  But  this,  in  healthy  children,  is  heard  all  over  the 
chest.  Enlarged  glands  alter  them  in  circumscribed  areas.  Thus 
when  large  we  maj^  find  feeble  breathing  over  a  limited  area  owing  to 
compression  of  a  bronchus,  or  to  modifications  in  the  pulmonary 
circulation  in  that  region.  On  rare  occasions  the  breath  sounds  are 
feeble  over  an  entire  lung  anteriorly  and  posteriorly.  But  this  is  liable 
to  great  fluctuations.  I  have  followed  some  children  for  years  and 
found  that  at  times  there  are  modiflcations  in  the  breath  sounds  in  a 
giveii  area  which  shift  so  that  at  the  next  examination  one  or  more 
months  later,  the  modification  is  found  at  another  place.  It  may  be 
found  that  during  an  attack  of  an  intercurrent  disease,  rhinopharyn- 
gitis, influenza,  etc. — when  the  glands  swell  up  and  there  is  an  exacer- 
bation of  the  tuberculous  process — ^the  auscultatory^  phenomena  make 
their  appearance  to  disappear  after  the  acute  process  is  gone. 

1  Amer.  Jour.  Med.  Sci.,  1909,  cxxxviii,  815;    1913,  cxlvi,  660. 

2  Sixth  Intern.  Congr.  on  Tuberculosis,  1908,  vi,  197. 

3  Brit.  Med.  Jour.,  1912,  ii,  966.  ■•  Birmingham  Med.  Review,  1912,  xix,  57. 

25 


386  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

Anteriorly  the  auscultatory  signs  in  children  are  uncertain,  because 
normally  we  may  hear  the  tracheal  sound  at  the  sides  of  the  manu- 
brium in  emaciated  children  with  narrow  chests.  Still,  when  tubular 
breathing  is  heard  unilaterally  at  the  side  of  the  sternum  it  speaks 
for  enlarged  glands.  Posteriorly,  bronchial  or  harsh  breathing  in 
the  interscapular  space  of  one  side  is  an  indication  of  the  transmis- 
sion of  the  tracheal  murmur  by  enlarged  glands  which  act  as  sound 
conductors.  In  mild  cases  only  prolonged  expiration  is  heard  in  one 
interscapular  space,  but  in  those  in  which  the  glands  are  very  much 
enlarged,  the  breathing  over  a  limited  area  may  be  tubular  or  exquis- 
itely bronchial,  almost  the  same  as  is  audible  when  listening  directly 
over  the  trachea. 

D'Espine's  Sign:  Tracheophony. — ^About  twenty-five  years  ago  A. 
d'Espine^  described  a  sign  of  enlarged  tracheal  glands  which  is  more 
satisfactory  than  any  other  symptom  or  sign.  It  consists  in  ausculta- 
tion of  the  voice,  especially  the  whispered  voice,  along  the  course  of 
the  treachea  posteriorly.  He  described  this  sign  as  follows:  The 
patient  is  told  to  count  "one,  two,  three,"  or  "thirty- three,"  as 
clearly  as  possible  (younger  children  may  be  told  to  say  "papa," 
"mamma")  while  the  examiner  auscultates  with  the  naked  ear,  or 
better  with  a  stethoscope,  the  spines  of  the  cervical  vertebrae.  As  long 
as  we  listen  to  the  cervical  spines,  we  hear  the  characteristic  tracheal 
tone  and  each  word  is  quite  clear.  In  the  normal  child  this  clear 
voice  stops  abruptly  as  soon  as  we  reach  the  seventh  cervical  spine 
and  the  lung  begins;  but  in  cases  with  bronchial  adenitis  the  clearness 
of  the  voice  or  the  tracheal  tone  continues  lower  down  from  the  first 
to  the  fifth  thoracic  vertebra.  It  is  at  this  spot  that  the  main  locali- 
zation of  the  enlarged  bronchial  glands  is  found.  The  transmission  of 
the  tracheal  tone  in  these  cases  is  effected  by  the  enlarged  glands  which 
surround  the  trachea  at  its  bifurcation  and  often  reach  the  spinal 
column,  acting  as  sound  conductors  between  the  trachea  and 
spine. 

When  auscultation  of  the  full  voice  gives  uncertain  results,  the 
patient  is  told  to  whisper  "thirty-three,"  which  is  even  more  reliable 
than  the  bronchophony  just  spoken  of.  It  must  always  be  borne  in 
mind  that  in  healthy  children  and  adults,  the  bronchophony  and  the 
whispered  voice  stop  abruptly  at  the  seventh  cervical  spine,  and  when 
heard  lower  it  is  a  sure  sign  of  something  interposing  between  the 
trachea  and  the  spine,  and  acting  as  a  voice  conductor. 

This  sign  of  tracheobronchial  adenopathy  has  been  extensively 
tried  in  France  and  many  report  that  it  is  more  reliable  than  any 
other  sign.  Barot^  found  it  superior  to  percussion  and  even  more 
trustworthy  than  skiagraphy  for  the  purpose  of  ascertaining  the 
presence  or  absence  of  enlarged  thoracic  glands.     In  this  country  it 


1  Traite  des  Malad.  de  I'enfance,  Paris,  1900,  p.  856. 

2  Arch,  medicales  d'Angers,  1907,  xii,  18. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  387 

has  been  strongly  recommended  by  Stoll,  Sewall/  Howell,^  Honeij,^ 
and  others. 

In  evaluating  this  sign  it  must  be  borne  in  mind  that  the  height 
of  the  bifurcation  of  the  trachea,  where  the  glands  are  most  likely 
to  become  enlarged  in  tuberculosis,  differs  according  to  the  age  of  the 
patient.  In  infants  and  young  children  it  is  on  a  level  with  the  seventh 
cervical  vertebra.  But  with  advancing  age  it  sinks  lower  and  lower. 
At  the  age  of  eight  it  reaches  the  second  or  third  thoracic  vertebra  and 
at  twelve  it  is  found  as  low  as  the  fourth.  In  adults,  especially  in 
senile  individuals,  it  may  be  found  as  low  as  the  fifth  or  sixth  thoracic 
vertebra.  Therefore,  in  a  child  of  ten  the  transmission  of  the  whispered 
voice  to  the  third  thoracic  vertebra  may  not  mean  enlarged  glands  in 
the  chest. 

It  must  also  be  emphasized  that  the  mere  transmission  of  the  vocal 
resonance  as  heard  over  normal  lungs  is  not  d'Espine's  sign.  This  is 
found  very  often  in  children  without  enlarged  glands.  It  is  the  trans- 
mission of  the  characteristic  tracheal  timbre  which  counts.  In  most 
cases  it  is  heard  not  only  along  the  spine,  but  also  in  the  interscapular 
space  on  one  side;  at  times  bilaterally. 

I  have  tested  this  sign  in  various  ways  and  found  it  most  satisfac- 
tory. In  several  cases  the  skiagraphic  plate  failed  to  disclose  the  pres- 
ence of  enlarged  glands  while  d'Espine's  sign  revealed  them.  Armand 
Dellile,^  Zabel,^  and  d'Espine  mention  cases  which  were  verified  by 
autopsy. 

Smith's  Sign.  —  Eustace  Smith's  sign  of  bronchical  adenopathy 
remains  to  be  mentioned.  It  consists  in  this:  If  the  child  be  made  to 
bend  back  the  head,  so  that  the  face  becomes  almost  horizontal,  and 
the  eyes  look  straight  upward  at  the  ceiling  above  him,  a  venous  hum, 
varying  in  intensity  according  to  the  size  and  position  of  the  diseased 
glands,  is  heard  with  the  stethoscope  placed  upon  the  upper  bone  of 
the  sternum.  As  the  chin  is  now  slowly  depressed,  the  hum  becomes 
less  loudly  audible  and  ceases  shortly  before  the  head  reaches  its 
ordinary  position.  Smith  explains  this  phenomenon  in  this  fashion: 
While  the  head  is  bending  backward,  the  lower  end  of  the  trachea  is 
tilted  forward,  carrying  with  it  the  glands  lying  in  its  bifurcation,  and 
the  left  innominate  vein,  as  it  passes  behind  the  first  bone  of  the 
sternum,  is  compressed  between  the  enlarged  glands  and  the  bone. 

In  my  own  experience  this  sign  is  not  very  reliable.  It  is  found  in 
short-necked  children  without  enlarged  glands,  and  is  absent  in  many 
with  adenopathy.  Gibson''  pointed  out  that  it  is  mostly  found  in 
children  who  have  enlarged  veins  in  the  neck  and  on  the  chest. 


1  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  2027. 

2  Amer.  Jour.  Dis.  Child.,  1915,  x,  90. 

3  Jour.  Amer.  Med.  Assn.,  1913,  Ivii,  958. 

^  Diagnostic  et  traitement  de  I'adenopathie  tracheo-bronchique,  Paris,  1911. 

5  Milnch.  med.  Wchnschr.,  1912,  lix,  2664. 

6  Brit.  Med.  Jour.,  1906,  ii,  1051, 


388  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

Reflex  Symptoms. — There  are  other  symptoms  of  tracheobronchial 
adenopathy  which  are  described  in  great  detail  in  text-books,  but 
which  are  in  fact  very  rare  and  may  be  left  out  of  consideration  in  the 
average  case.  Thus,  pressure  on  the  recurrent  nerve  may  produce 
paralysis  of  the  right  vocal  cord;  pressure  on  the  sympathetic  may 
produce  differences  in  the  size  of  the  pupils.  Pressure  on  the  vagus 
may  produce  tachycardia  and  palpitation,  transient  or  permanent. 
But  these  symptoms  are  very  rare  and  are  not  conclusive  even  when 
encountered. 

In  young  children  caseated  glands  may  break  through  into  adjoin- 
ing structures,  the  bronchi,  trachea,  esophagus,  etc.  More  rarely 
yet,  the  swollen  glands  acquire  such  dimensions  that  by  pressure  on 
a  bronchus  they  prevent  the  entry  of  air  into  the  part  of  the  lung 
supplied  by  this  tube;  or  by  pressure  on  the  trachea  fatal  asphyxia  is 
produced.  But  these  cases  are  extremely  rare  and  may  be  considered 
medical  curiosities. 

Skiagraphy. — With  the  enthusiasm  of  the  first  years  of  radiography, 
we  thought  that  with  the  aid  of  the  a'-rays  we  had  at  last  found  a 
means  for  positively  identifying  enlarged  tracheobronchial  glands. 
Radiographers  often  made  diagnoses  of  tuberculosis  in  children  who 
showed  no  symptoms  of  active  disease  and  continued  well  indefinitely. 

This  w^as  but  natural,  considering  that  normal  glands  allow  the  rays 
to  pass  through  without  casting  any  shadows,  unless  there  is  engorge- 
ment. Caseated  glands  cast  a  shadow  which  is  occasionally  distinct, 
but  at  times  very  indefinite.  Only  calcified  glands  cast  a  distinct 
shadow  which  may  be  identified  in  the  vast  majority  of  cases.  But 
calcified  glands,  tuberculous  in  origin  undoubtedly,  are  an  indication 
that  the  disease  has  come  to  a  standstill ;  in  fact  this  is  the  only  mode 
of  cure  of  caseated  glands. 

Under  the  circumstances  the  most  easily  diagnosticated  cases  of 
tracheobronchial  adenitis,  when  the  x-rays  are  used  for  the  purpose, 
are  those  which  have  no  significance  clinically — those  with  calcified 
glands.  When  we  attempt  to  clear  up  a  case  in  which  the  glands  are 
swollen  but  neither  caseated  nor  calcified — in  other  words,  at  a  time 
when  therapeutic  measures  may  be  inaugurated  with  a  good  chance 
of  helping  the  patient — the  .r-rays  very  frequently  fail  to  give  conclusive 
proofs  of  the  existence  of  trouble.  On  the  other  hand,  they  show  old 
and  calcified  glands  which  may  not  be,  and  often  are  not,  the  cause 
of  the  clinical  symptoms  for  which  the  patient  consults  us  at  the  time. 

Fluoroscopy  is  of  no  value  at  all  in  most  cases  of  young  children  who 
cannot  be  managed  in  a  totally  dark  room,  and  asked  to  breathe 
deeply,  cough,  etc.  The  best  is  a  skiagraphic  plate  taken  instanta- 
neously and  studied  after  it  is  developed.  But  even  here  we  must  be 
careful  before  concluding  that  because  there  is  a  shadow  at  the  hilus, 
there  is  active  tuberculosis  of  the  intrathoracic  glands.  In  nearly 
all  infectious  diseases  of  childhood,  but  especially  in  scarlet  fever, 
measles  and  whooping  cough,  these  glands  are  enlarged,   but  the 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  389 

swelling  slowly  retrogresses  during  convalescence.  In  fact  de  Mussey 
attributed  the  paroxysms  of  cough  in  pertussis  to  enlarged  glands.  It 
is  therefore  wrong  to  diagnose  tuberculous  adenitis  in  a  child  with 
whooping-cough,  or  scarlet  fever,  as  I  have  seen  done. 

Sluka^  insists  that  several  plates  taken  at  long  intervals  are  necessary, 
so  that  evanescent  enlargements  of  the  glands  may  be  excluded.  In 
fact  he  found  that  the  shadows  shown  on  the  plate  of  the  same  child 
at  irregular  intervals  have  been  larger  at  one  time  and  smaller  at 
another;  at  times  involving  almost  a  complete  lobe,  or  even  a  whole 
lung,  at  other  times  only  a  small  circumscribed  shadow  was  found;  at 
one  time  in  the  right  side,  at  other  times  in  the  left,  etc.  A  consider- 
able part  of  these  changes  is  due  to  changes  in  the  collateral  inflam- 
mation in  active  cases,  but  it  seems  to  me  that  differences  in  the 
technic  of  taking  the  picture,  the  distance  of  the  tube  from  the  patient's 
chest,  the  sharpness  of  the  focus,  the  condition  of  the  tube,  etc.,  are 
responsible  in  many  cases. 

On  the  whole  there  is  no  doubt  that  shadows  in  the  region  of  the  hilus 
are  indicative  of  enlargement  or  engorgement  of  the  glands  in  that 
region.  This  mottling  and  stippling  of  the  hilus  is,  however,  no  cri- 
terion as  to  the  activity  of  the  disease.  Even  the  triangular  or  wedge- 
shaped  shadow,  with  the  base  to  the  hilus,  which  has  been  described 
by  Stoll  and  Heublein,  Sluka  and  others,  is  no  proof  of  active  disease, 
as  the  writer  has  repeatedly  convinced  himself.  It  appears  also  that 
in  young  infants  these  hilus  shadows  are  only  rarely  seen  even  when 
adenopathy  exists.  Sluka  says  that  in  children  under  two  years  of 
age  he  never  obtained  a  shadow  on  a  chest  plate  which  would  even 
remotely  suggest  hilus  tuberculosis,  though  he  has  taken  numerous 
plates  of  sick  children.  He  says  that  only  during  the  third  and  fourth 
year  do  the  glands  begin  to  reveal  themselves  roentgenologically;  they 
are  mostly  seen  during  the  sixth  and  seventh  years,  and  then  begin  to 
decrease  in  frequency. 

Of  late  the  confidence  formerly  placed  in  x-ray  findings  in  intra- 
thoracic conditions  has  been  waning.  At  the  1915  meeting  of  the 
American  Pediatric  Society,^  Koplik  said  that  "one  should  be  very 
cautious  in  permitting  an  a-ray  to  make  a  diagnosis  for  him."  Holt 
stated  that  he  had  "sent  the  same  case  to  a  radiologist  on  successive 
days  and  each  day  a  different  diagnosis  was  made.  The  rr-ray  is  very 
misleading  and  a  dubious  procedure  upon  which  to  base  a  diagnosis." 

In  doubtful  cases  the  skiagraphic  plate  may  give  some  indefinite 
information  about  the  presence  of  enlarged  thoracic  glands.  But  when 
found  in  a  child  showing  no  clinical  symptoms  of  the  disease,  we  must 
not  conclude  that  the  child  is  actively  tuberculous.  We  do  not  as  yet 
have  enough  experience  with  skiagraphy  in  healthy  children,  nor  have 
enough  autopsies  been  made  to  verify  skiagraphic  findings,  to  warrant 
unequivocal  conclusions. 

1  Wien.  klin.  Wchnschr.,  1913,  xxvi,  254. 

2  Medical  Record,  1915,  Ixxxviii,  502. 


390  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

Tuberculin  Diagnosis. — ^Basing  their  opinion  on  the  fact  that  tuber- 
culosis in  infants  is  almost  invariably  fatal,  it  has  been  concluded  that 
when  in  a  young  child  any  of  the  tuberculin  tests  is  positive,  and  there 
are  some  symptoms, 'such  as  cough,  etc.,  the  child  should  be  pronounced 
tuberculous  to  the  great  dismay  of  the  parents.  I  have  seen  children 
kept  from  school  and  thus  deprived  of  an  education,  and  perhaps 
hampered  for  the  rest  of  their  lives,  solely  because  the  von  Pirquet 
reaction  was  found  positive. 

We  have  already  shown  that  the  tuberculin  reaction  shows  but  one 
thing — whether  the  person — child  or  adult  immaterial — ^has  ever  been 
infected  with  tubercle  bacilli.  But  it  does  not  show  conclusively 
whether  the  infection  was  followed  by  disease.  Inactive  infection  is 
more  likely  to  give  a  strong  reaction  than  active  tuberculous  disease. 
In  fact,  in  fatal  tuberculous  bronchopneumonia,  meningitis,  etc.,  the 
reaction  is  negative;  in  others  it  is  but  faintly  positive.  In  other 
words,  the  stronger  the  reaction,  the  less  likelihood  of  active  or 
dangerous  disease  in  the  child,  and  a  negative  reaction  is  no  positive 
proof  of  the  absence  of  dangerous  tuberculous  disease. 

In  infants  under  two  years  of  age  a  positive  reaction  is  to  be  taken 
as  an  indication  of  active  disease  because  at  that  age  infection  is  very 
likely  to  be  followed  by  disease;  during  the  first  six  months  of  life, 
almost  invariably.  But  after  two  years  of  age  harmless  infections 
are  the  rule,  so  that  the  value  of  the  tuberculin  reaction  acquires  an 
academic  importance,  as  was  already  shown,  but  it  loses  its  clinical 
value.  This  is  a  point  which  pediatrists  should  bear  in  mind.  It  should 
never  be  lost  sight  of  that  after  the  third  year  latent  tuberculosis  is 
very  common  and  this  gives  the  same  reaction  as  active  disease. 

Diagnosis.^The  diagnosis  of  tuberculous  tracheobronchial  aden- 
opathy depends  on  the  presence  or  absence  of  clinical  symptoms  of 
disease.  A  child  over  two  years  of  age  showing  a  three  plus  tuberculin 
reaction,  and  a  shadow  in  the  region  of  the  hilus  on  the  skiagraphic 
plate  is  to  be  considered  well  and  healthy  as  long  as  it  presents  no  symp- 
toms of  disease;  as  long  as  there  is  no  fever,  no  cough,  no  emaciation, 
etc.  It  is  different  with  those  who  have  clinical  symptoms.  In  these 
it  is  always  important  to  remember  that  when  a  child  does  not  thrive, 
fails  to  gain  in  weight,  the  cause  must  be  found.  If  it  is  not  found, 
and  there  is  cough,  especially  that  dry,  brassy  cough,  the  temperature 
is  to  be  taken  three  or  four  times  a  day.  If  it  is  found  that  there  is 
an  irregular  fever,  of  the  type  described  above,  there  is  presumption 
of  tuberculosis.  If  on  examining  the  chest  we  find  some  dulness  in 
one  of  the  interscapular  spaces  or  anteriorly  in  the  upper  two  inter- 
spaces near  the  sternum;  and  the  whispered  voice  and  the  tracheal 
tone  along  the  spine,  and  in  one  or  both  interscapular  spaces  are 
audible  in  the  peculiar  characteristic  fashion  described  when  speaking 
of  d'Espine's  sign,  the  diagnosis  of  tracheobronchial  adenopathy  is 
clinched. 

It  is  different  when  these  signs  are  found,  even  in  conjunction  with 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  391 

skiagraphic  findings  and  a  positive  tuberculin  reaction,  in  a  child  which 
shows  no  clinical  symptoms  of  disease.  There  is  no  doubt  that  this 
child  may  also  have,  and  probably  does  have,  enlarged  bronchial  glands. 
But  these  glands  are  not  actively  diseased,  and  as  long  as  the  little 
patient  thrives,  there  is  no  cause  for  alarm.  The  glands  are  of  no  more 
clinical  value  than  the  scars  found  in  the  apices  of  90  per  cent,  of  adults 
who  die  from  causes  other  than  tuberculosis;  they  are  of  no  more 
serious  import  than  the  enlarged  glands  found  on  the  necks  of  over 
50  per  cent,  of  evidently  healthy  children  in  the  slums  of  large  cities. 

Prognosis. — ^The  prognosis  of  tuberculosis  in  children  under  ten 
years  of  age  embraces  two  problems:  (1)  The  immediate  outlook;  and 
(2)  the  ultimate  outlook.  In  other  words,  what  are  the  chances  of 
survival  or  of  retaining  good  health  immediately  after  infection  has 
taken  place,  and  is  the  child  destined  to  develop  phthisis  after  reaching 
the  age  of  adolescence? 

The  immediate  outlook  appears  to  be  good,  provided  the  lesions 
remain  localized  in  the  glands  or  even  in  the  bones  and  joints.  This 
is  clearly  seen  in  cases  of  superficial  glandular  tuberculosis:  Most 
children  with  tuberculous  cervical  adenitis,  especially  those  requiring 
no  operative  interference,  recover  after  a  protracted  illness.  The 
same  is  true  of  osseous  and  articular  tuberculosis.  From  900  cases  of 
tuberculous  disease  of  the  hip  treated  by  A.  Bowlby^  at  the  Alexandra 
Hospital  in  London  during  twenty-one  years,  33  died — a  mortality  of 
4  per  cent.  He  found  that  of  the  33  who  died,  24  were  attacked  by  the 
disease  before  the  age  of  six.  The  mortality  from  tuberculous  tracheo- 
bronchial adenitis  is  undoubtedly  even  lower.  The  greatest  danger  is 
metastasis  in  the  meninges,  but  even  this  is  comparatively  infrequent 
after  the  fifth  year. 

For  this  reason  all  methods  of  treatment  of  tuberculosis  in  children 
produce  most  excellent  results.  This  is  also  the  reason  why  orphan 
asylums — which  harbor  children  between  four  and  fourteen  years  of 
age — -report  that,  despite  the  fact  that  most  of  their  inmates  are 
derived  from  the  poorest  strata  of  population  and  an  enormous  pro- 
portion are  of  tuberculous  stock,  they  have  no  morbidity  nor  mor- 
tality from  tuberculosis.  It  is  simply  because  death  from  tuberculous 
tracheobronchial  adenopathy  is  extremely  rare.  The  success  of  the 
open  air  schools,  the  preventoriums,  etc.,  should  also  be  attributed 
in  a  great  measure  to  this  cause. 

Barring  meningeal  complications,  or  intercurrent  diseases,  the  prog- 
nosis in  tracheobronchial  adenopathy  is  excellent. 

In  older  children,  seven  years  of  age  or  more,  the  prognosis  of 
apical  pulmonary  tuberculosis  of  the  same  type  as  seen  in  adults,  is 
more  serious,  though  not  as  serious  as  in  adults.  It  appears  that  pul- 
monary lesions  in  children  heal  with  greater  ease  than  in  adults, 
though  now  and  then  we  meet  with  a  case  in  which  the  process  in  the 

I  1  Brit.  Med.  Jour.,  1908,  i,  1465. 


392  PULMONARY  TUBERCULOSIS  IN  CHILDREN 

lung  proceeds  to  cavitation  and  the  child  succumbs  to  the  usual  clinical 
manifestation  of  phthisis.  After  the  twelfth  year  there  is  hardly  any 
difference  in  the  clinical  picture  and  prognosis  of  phthisis  in  children 
and  in  adults. 

Says  Franz  Hamburger/  one  of  the  most  experienced  men  in  this 
field :  "  In  general  we  can  lay  dow^n  the  fundamental  principle  that  the 
prognosis  of  tuberculous  manifestations  in  children  is  not  at  all  bad. 
It  is,  in  fact,  one  of  the  most  important  achievements  of  recent  years 
that  we  know:  'tuberculosis  in  children  is  a  relatively  harmless 
disease.'  It  will  naturally  take  decades  till  the  lay  public  will  learn 
this  important  fact."  And  I  may  add  till  physicians  in  general  will 
learn  it. 

The  prognosis  also  depends  on  several  other  factors:  The  younger 
the  child  showing  active  tuberculous  manifestations,  the  worse  the 
outlook,  the  more  liable  it  is  to  suffer  from,  or  to  succumb  to,  metas- 
tatic tuberculous  manifestations,  such  as  meningitis,  rupture  of  a 
gland  into  a  bronchus,  the  trachea  or  esophagus.  These  complications 
in  fact  become  less  frequent  after  the  third  year  of  life,  and  after  the 
sixth  year  they  are  comparatively  rare.  The  prognosis  also  depends 
on  various  accidental  complications.  Thus,  a  child  that  escapes  the 
endemic  diseases,  such  as  measles,  whooping  cough,  scarlet  fever, 
diphtheria,  etc.,  may  grow  up  into  healthy  manhood  in  spite  of  the 
enlarged  glands  in  the  chest  which  disappear  in  nearly  all  cases  after 
the  tenth  year;  at  any  rate  they  no  more  give  trouble.  It  is  thus  clear 
that  the  prognosis  also  depends  on  the  social  and  economic  conditions 
under  which  the  child  is  raised.  Those  who  are  well  off  in  this  regard 
survive  unscathed,  because  they  have  good  nourishment,  health}^ 
dwellings,  frequent  vacations  and  are  less  likely  to  contract  other 
diseases,  etc. 

The  second  element  in  the  prognosis  of  tuberculosis  during  childliood 
is  the  problem  whether  every  child  infected  at  an  early  age  is  destined 
to  become  phthisical  after  the  fifteenth  year  of  life?  The  facts  ob- 
served in  daily  practice  seem  to  be  against  such  a  view.  If  this  were 
the  case  tuberculosis  among  adults  would  not  kill  only  one  out  of 
seven  to  ten  individuals,  as  is  now  found  wherever  there  are  available 
vital  statistics,  but  over  90  per  cent,  of  humanity  would  succumb 
to  phthisis.  That  an  active  tuberculous  lesion  during  childhood  is 
not  necessarily  followed  by  phthisis  in  later  life  is  evident  from  the 
following  facts: 

We  meet  with  many  persons  showing  unmistakable  signs  of  having 
had  some  form  of  tuberculosis  during  childhood,  but  pass  through 
life  as  healthy  and  even  vigorous  individuals.  This  is  the  case  with 
those  showing  scars  on  the  neck  which  are  undoubtedly  remnants  of 
tuberculous  adenitis  which  had  suppurated  or  were  operated  upon. 
We  meet  with  many  showing  remnants  of  articular  and  osseous  tuber- 

1  In  Brauer,  Schroder,  and  Blumenfeld,  Handbuch  der  Tuberkulose,  1915,  v,  31. 


TUBERCULOSIS  DURING  EARLY  CHILDHOOD  393 

culous  disease,  yet  they  pass  through  life  without  developing  phthisis. 
In  fact  the  contrary  seems  to  be  true.  Those  who  see  large  numbers  of 
phthisical  patients  are  struck  by  the  fact  that  consumptives  with 
scars  on  the  neck,  or  with  ankylosis  of  joints  following  earlier  tuber- 
culosis, etc.,  are  extremly  rare.  This  point,  which  has  already  been 
touched  upon  (see  p.  112),  seems  to  indicate  that  an  early  tuberculous 
lesion  may  have  some  immunizing  effect  on  the  organism  and  prevent 
the  development  of  phthisis  in  later  life. 

We  are,  at  the  present  state  of  our  knowledge,  not  warranted  in 
asserting  that  this  protection  against  phthisis  conferred  by  a  early 
tuberculous  disease  depends  on  infection  with  bovine  tubercle  bacilli,  as 
some  have  been  inclined  to  assume.  But  we  may  safely  draw  a  conclu- 
sion that  an  early  tuberculous  disease  of  the  tracheobronchial  glands 
is  not  necessarily  followed  by  phthisis  in  later  life,  and  there  seems  to 
be  evidence  that  it  may  act  in  the  same  manner  as  articular,  osseous, 
and  glandular  tuberculosis. 


CHAPTER  XXV. 
PHTHISIS  IN  THE  AGED. 

Frequency. — While  discussing  the  frequency  of  tuberculosis  during 
the  various  age  periods  we  have  shown  that  no  age  is  exempt;  in  fact 
it  appears  from  available  mortality  statistics  that  after  the  age  of 
twenty  the  death-rates  from  phthisis  are  about  the  same  till  very 
advanced  life.  While  making  autopsies  pathologists  are  often  struck 
with  the  frequency  with  which  active  tuberculous  lesions  are  found  in 
the  lungs  of  aged  persons,  and  investigations  in  homes  for  the  aged  show 
clearly  that  a  large  proportion  suffer  from  phthisis. 

The  reason  why  popular  opinion  has  ascribed  immunity  of  old  sub- 
jects to  phthisis  appears  to  lie  in  the  fact  that,  when  occurring,  this 
disease  runs  a  mild,  benign  course  and  may  pass  off  as  bronchitis, 
asthma,  etc.  But  when  the  sputum  expectorated  by  senile  persons  is 
examined,  it  is  very  frequently  found  to  contain  large  numbers  of 
tubercle  bacilli.  In  fact  these  aged  consumptives  may  be  considered 
actual  bacillus  "carriers"  who,  without  themselves  suffering  very 
much  from  the  bacilli,  disseminate  the  disease  much  more  widely 
than  younger  patients  who  know  of  their  condition  and  the  dangers 
of  indiscriminate  expectoration. 

Etiology. — Most  phthisis  in  the  aged  has  been  acquired  during 
childhood,  but  has  been  held  in  abeyance  throughout  life,  to  break  out 
again  at  the  period  of  life  when  the  organs  of  the  body  begin  to  suffer 
as  a  result  of  wear  and  tear.  Others  have  suffered  from  some  form  of 
phthisis  before,  but  the  disease  was  "cured,"  to  reawaken  during  old 
age.  Many  have  been  afflicted  for  years  with  some  form  of  fibroid 
phthisis,  but  when  senile  degeneration  began  to  manifest  itself  the 
tuberculofibroid  lesions  in  the  lungs  began  to  activate  with  more  vigor. 

From  our  present  knowledge  of  phthisiogenesis  we  must  exclude 
new  infections  of  aged  persons,  because  they  have  been  infected  during 
the  earlier  years  of  life,  as  was  already  discussed  elsewhere.  A  new 
or  primary  infection  in  an  adult  would  surely  not  pursue  such  a  slow, 
sluggish  course  as  is  seen  in  the  aged.  The  active  disease  in  senile 
individuals  should  be  considered  either  metastatic  or  else  old,  perhaps 
dormant  processes  flaring  up  and  causing  disease. 

Pathologically,  there  are  no  differences  in  the  lesions  between  the  aged 
and  those  in  adults  in  general,  with  but  few  exceptions.  In  the  aged 
the  fibroid  processes  predominate  because  the  tendency  to  fibrosis  of  tis- 
sues is  characteristic  of  advancing  age.  These  fibroid  formations  tend 
to  limit  the  lesions,  prevent  its  spread  and  to  surround  the  cavities, 


SYMPTOMS  395 

which  show  no  tendency  to  enlarge  by  contiguity  of  the  process.  On 
the  other  hand,  bronchiectatic  cavities  are  more  frequently  found  in 
old  than  in  young  consumptives. 

Symptoms. — "The  conditions  with  which  it  may  be  associated 
modify  the  course  of  the  tuberculous  process,"  says  J.  Edward  Squires,^ 
"so  that  the  symptoms  are  obscured  and  the  signs  of  its  presence  in 
the  lung  are  somewhat  indistinct.  Tuberculosis,  when  it  attacks 
lungs  already  damaged  by  the  degeneration  of  age,  may  add  but  little 
to  the  discomforts  of  the  individual  who  is  already  short  of  breath  and 
'wheezy.'  The  increasing  infirmity  of  the  patient  is  accepted  as  a 
sign  that  he  is  aging  more  rapidly,  and  no  suspicion  of  any  added  mis- 
chief is  aroused  or  entertained."  Generally  speaking  the  symptoms  of 
phthisis  in  the  aged  are  often  those  of  fibroid  phthisis,  which  have 
already  been  described.  From  most  patients  who  consult  us  for  hemop- 
tysis, cough,  expectoration,  and  a  lesion  is  discovered  on  physical 
examination,  we  elicit  a  history  that  they  have  been  troubled  with 
some  of  these  symptoms  for  years,  perhaps  since  childhood,  but  that 
they  have  been  considered  as  suffering  from  chronic  bronchitis  or 
pulmonary  emphysema. 

The  patients  cough,  but  the  cough  is  mild.  In  aged  persons  the 
stimulus  for  cough  is  not  as  intense  as  in  the  young  because  the  sensi- 
bility of  the  bronchial  mucous  membrane  is  greatly  diminished.  The 
quantity  of  sputum  they  expectorate  is,  as  a  rule,  not  very  consider- 
able because  they  have  a  tendency  to  swallow  it.  When  told  that 
they  are  tuberculous  they  are  apt  to  resent  the  imputation  claiming 
that  they  have  coughed  for  years,  perhaps  since  they  can  recall,  and 
if  it  had  been  "consumption"  they  would  have  succumbed  long  ago. 

Most  senile  patients  are  of  slim  build,  but  occasionally  we  meet  with 
a  tuberculous  patient  over  sixty  who  is  above  the  average  weight. 
But  with  the  onset  of  active  symptoms  they  begin  to  lose  in  weight, 
and  within  a  few  months  they  may  be  reduced  to  mere  skeletons. 

A  large  proportion  of  patients  have  no  fever,  though  the  methodical 
use  of  the  thermometer  per  rectum  may  reveal  a  typical  tuberculous 
temperature  with  slight  rises,  to  101°  F.  in  the  afternoon.  In  this 
respect  phthisis  does  not  differ  from  other  diseases  in  the  aged.  We 
know  that  pneumonia  may  pass  an  afebrile  course  in  the  senile.  The 
organism  of  the  aged  does  not  react  with  fever  as  does  the  body  of 
the  young. 

The  pulse  is  more  rapid  than  normal  for  the  age  of  the  patent.  In 
rare  cases  tachycardia  is  seen,  especially  when  there  is  cardiac  dis- 
placement. Dyspnea  is  a  frequent  symptom,  especially  after  exertion. 
Because  of  the  concomitant  arteriosclerosis  and  myocarditis,  cyanosis 
is  not  uncommon.  In  the  later  stages,  when  heart  failure  is  apt  to 
occur,  edema  of  the  extremities  is  frequently  seen.  The  blood-pressure 
is  low  considering  the  age  and  the  condition  of  the  arteries  of  the 

1  International  Clinics,  Sixteenth  Series,  1906,  iv,  90. 


396  PHTHISIS  IN   THE  AGED 

patient.  Hemoptysis  occurs  quite  frequently.  In  most  cases  it  is 
merely  streaky  sputum,  but  it  may  be  profuse  and  I  have  seen  a  fatal 
hemorrhage  in  a  woman,  aged  seventy-eight  years.  Nightsweats  are 
rare  because  with  advancing  age  the  sweat  glands  undergo  atrophy, 
and  also  because  the  great  oscillations  of  temperature  characteristic 
of  phthisis  in  the  young  are  absent  in  the  senile. 

Physical  Signs. — The  appearance  of  the  senile  phthisical  chest 
depends  on  the  character  of  the  lesions  in  the  lungs.  In  those  in  whom 
there  is  pulmonary  emphysema  in  addition  to  the  tuberculous  process 
there  fs  the  characteristic  barrel-shaped  chest,  rigid,  hardly  expanding, 
in  fact  always  in  the  position  of  maximum  inspiration.  All  that  is 
seen  is  that  the  entire  chest  is  lifted  up  with  each  inspiration,  but  there 
is  no  anteroposterior  or  lateral  expansion.  The  intercostal  spaces  are 
wide  and  the  direction  of  the  ribs  is  more  horizontal  than  normal. 
But  many  have  no  old  emphysema  and  in  them  the  thorax  is  rigid 
owing  to  the  ossification  of  the  costal  cartilages;  the  ribs  run  at  a 
more  acute  angle  to  the  spine  than  normal  and  the  intercostal  spaces 
are  wider;  the  supraclavicular  and  infraclavicular  spaces  are  deeply 
excavated,  more  so  on  one  side.  During  fits  of  coughing  either  apex 
or  both,  may  be  seen  blowing  up  in  the  supraclavicular  space.  Dilata- 
tion of  the  veins  of  the  neck  is  a  frequent  symptom,  and  when  there  is 
relative  tricuspid  insufficiency,  owing  to  dilatation  of  the  right  heart, 
there  may  be  a  venous  pulse.  Kyphosis  and  kj^Dhoscoliosis  is  never 
absent. 

Auscultation  is  also  not  as  satisfactory  as  in  young  subjects.  The 
breathing  is  superficial  and,  combined  with  pulmonary  emphysema 
which  is  only  rarely  absent,  we  may  hardly  hear  any  breath  sounds, 
or  only  a  feeble  murmur  is  audible.  These  are  also  the  reasons  why 
bronchial  or  cavernous  breathing  are  so  rarely  heard  over  the  sites 
of  cavities.  Bronchovesicular  breathing  of  low  pitch,  with  prolonged 
expiration  may,  however,  be  made  out  over  one  apex  at  times  while 
carefully  auscultating  the  chest.  Rales  are  not  audible  in  many  cases 
because  of  the  superficial  breathing;  but  over  the  sites  of  excavations 
large  consonating  rales  may  be  heard  even  when  no  breath  sounds 
are  made  out.  At  the  base  these  rales  are  usually  due  to  bronchitis  or 
bronchiectasis  which  are  very  frequent  in  old  age. 

Course. — In  many  cases  the  cough,  expectoration,  emaciation, 
etc.,  continue  for  years  and,  inasmuch  as  these  old  persons  do  not 
follow  occupations  necessitating  physical  exertion,  the  true  nature 
of  the  disease  is  not  even  suspected.  They  are  considered  patients 
suffering  from  chronic  bronchitis  or  emphysema.  I  know  several  old 
consumptives  who  have  survived  children  and  grandchildren  whom 
they  infected  with  tuberculosis.  In  fact,  whenever  I  discover  children 
with  signs  of  tuberculous  infection,  though  a  history  of  exposure  can- 
not be  made  out,  I  inquire  for  the  grandparents,  and  have  on  many 
occasions  found  that  one  of  them  was  the  source  of  infection,  though 
he  did  not  know  the  true  nature  of  his  illness. 


DIAGNOSIS  397 

In  the  vast  majority  of  cases  the  tendency  of  the  disease  is  to  pro- 
gress, though  slowly,  and  never  to  a  cure.  Occasionally  we  find  that 
it  advances  rapidly,  assuming  an  acute  or  subacute  course,  with  hectic 
fever,  rapid  emaciation,  etc.  Owing  to  the  weakness  and  the  general 
debility  the  cough  is  usually  not  at  all  severe,  and  when  there  is  no 
fever,  a  diagnosis  of  carcinomatosis  is  made.  Others  cough  and 
expectorate  for  years,  when  suddenly  fever  develops  and  the  patient 
is  carried  off  within  a  few  days.  Bronchopneumonia  may  have  been 
erroneously  considered  the  cause  of  death,  unless  the  sputum  was 
examined  and  tubercle  bacilli  were  found;  a  diagnosis  of  acute  pri- 
mary tuberculosis  may  then  be  erroneously  made.  Daremberg  speaks 
of  acute  phthisis  in  the  aged,  and  Hoppe-Seyler  speaks  of  acute  miliary 
tuberculosis  on  rare  occasions.  But  these  eases  are  evidently  acute 
exacerbations  of  chronic  phthisis  which  had  been  kept  in  abeyance  for 
years. 

Diagnosis. — The  diagnosis  is  not  difficult  when  the  possibility  of 
phthisis  is  kept  in  mind  in  all  cases  of  cough,  expectoration,  emacia- 
tion, etc.,  met  with  in  senile  patients.  Most  of  the  mistakes  made  in 
these  cases  are  due  to  failure  to  examine  the  sputum  for  tubercle 
bacilli.  When  the  physical  signs  in  the  chest  are  indefinite,  which  is 
often  the  case,  the  bacteriological  findings  decide.  When  looking 
for  fever  in  these  cases  we  should  never  rely  on  the  axillary  tempera- 
ture;   only  the  rectal  is  to  be  taken. 

We  must  guard  against  mistaking  signs  of  old,  healed  lesions  for 
active  disease.  This  can  be  avoided  by  a  careful  study  of  the  symp- 
tomatology and  bacteriology  of  the  affection. 


CHAPTER  XXVI. 
COMPLICATIONS  OF  PHTHISIS. 

Most  of  the  conditions  described  as  complications  of  phthisis  are 
part  and  parcel  of  the  tuberculous  disease  in  the  chest,  or  symptoms 
of  the  disease  which  at  times  assume  the  ascendency.  This  is  the  case 
with  hemoptysis,  ulcerations  and  amyloid  degeneration  of  the  intes- 
tines, bronchitis,  tuberculosis  of  the  kidneys,  etc.  These  have  been 
discussed  more  or  less  while  speaking  of  the  symptoms  of  phthisis. 
There  are,  however,  left  a  few  of  the  more  important  complications 
which  deserve  separate  description.  Among  these  pleurisy,  sponta- 
neous pneumothorax,  laryngeal,  intestinal,  and  meningeal  tuberculosis, 
etc.,  are  the  most  important. 

Dry  Pleurisy. — Inflammation  of  the  pleura  cannot  be  considered 
a  complication  of  phthisis  in  the  strict  sense  of  the  word,  because  it  is 
part  and  parcel  of  the  tuberculous  process  in  the  lung,  and  often  mani- 
fests itself  earlier  than  the  symptoms  of  the  disease,  as  was  already 
shown. 

During  the  course  of  phthisis  the  patient  often  complains  of  pains 
in  the  chest  which  last  for  several  days,  a  week  or  two,  and  then  pass 
away,  to  return  sooner  or  later  in  the  same  or  another  area.  Ausculta- 
tion may  reveal  friction  sounds,  etc.  These  frictions  are  mostly 
heard  over  the  lower  parts  of  the  thorax,  especially  in  the  anterior 
axillary  line.  But  pleural  inflammation  may  occur  during  the  course 
of  phthisis  without  causing  pains  in  the  chest. 

This  form  of  dry  pleurisy  is  not  always  to  be  considered  an  ominous 
complication  of  phthisis.  In  fact  it  is  a  rather  salutary  phenomenon 
in  many  cases.  The  fibrosis  it  causes  in  the  pleura  overlying  the 
tuberculous  lesion  in  the  lung,  as  well  as  the  adhesions  of  the  pleural 
layers  which  are  formed  as  a  result  of  it,  at  times  obliterating  the 
pleural  cavity,  prevent  the  tuberculous  lesion  in  the  lung  from  break- 
ing through  into  the  pleura.  Without  adhesive  pleurisy  spontaneous 
pneumothorax  would  be  a  very  frequent  complication  of  phthisis. 
It  appears  to  be  an  expression  of  the  efforts  of  nature  to  limit  the 
progress  of  the  disease;  it  limits  the  excursions  of  the  affected  part 
of  the  lung,  thus  affording  it  rest  which  is. essential  for  a  cure.  It  is 
also  an  indication  that  the  organism  responds  to  the  tuberculous  infec- 
tion with  a  productive  inflammation,  Avith  the  formation  of  connective 
tissue,  which  is  the  main  element  in  the  cure  of  the  disease. 

Pleurisy  with  Effusion. — Less  frequently  encountered  during  the 
course  of  phthisis  is  moist  pleurisy.  But  it  may  occur  at  any  stage  of 
the  disease.    When  occurring  at  the  onset  of  the  disease,  its  course 


PLEURISY  WITH  EFFUSION  399 

is  that  of  the  usual  attack  of  pleural  effusion,  excepting  that  the  patient 
must  be  watched  carefully  for  the  development  of  a  lung  lesion  after 
the  effusion  has  been  absorbed  or  aspirated,  as  has  already  been 
mentioned. 

In  the  advanced  stages  of  the  disease,  pleural  effusions,  serous  or 
purulent,  may  occur,  at  times  filling  the  greater  part  of  the  affected 
side  of  the  chest.  Localized,  encapsulated  and  interlobar  effusions. 
are  also  found  at  times.  In  fact,  because  the  pleura  is  more  or 
less  obliterated  in  most  advanced  cases,  effusion  when  occurring  can 
only  be  localized.  These  small  effusions  may  cause  no  special  symp- 
toms, and  if  the  patient  is  not  examined  frequently  and  with  minute 
care,  they  are  overlooked.  Skiagraphy  has  recently  shown  the  large 
number  of  small  effusions  that  otherwise  escape  notice. 

In  many  cases  a  copious  effusion,  even  if  serous,  is  a  serious  compli- 
cation, but  in  some  its  effects  are  either  negative,  or  altogether  benefi- 
cial. The  lung  is  compressed  in  the  same  manner  as  with  the  gas 
introduced  when  inducing  a  therapeutic  pneumothorax,  and  is  thus 
given  an  opportunity  to  heal.  The  writer  has  met  with  several  cases 
of  phthisis  in  which  a  serous  effusion  has  thus  favorably  influenced 
the  tuberculous  process  in  the  lungs. 

An  exception  is  to  be  considered  a  hemorrhagic  effusion  into  the 
pleura  which  in  itself  is  to  be  considered  characteristic  of  either  tuber- 
culosis or  cancer.  In  the  former  the  fluid  is  only  slightly  blood-stained, 
while  in  the  latter  the  proportion  of  blood  may  be  considerable.  In 
phthisis  sanguineous  effusions  are  of  serious  prognostic  importance. 
Purulent  effusions  are  always  ominous. 

The  onset  of  pleurisy  with  effusion  during  the  course  of  phthisis  is 
in  most  cases  acute,  with  pain  and  tenderness  in  the  inframammary 
and  axillary  regions,  increased  by  cough  and  deep  breathing.  The 
temperature,  in  cases  which  were  afebrile,  rises  to  101°  F.  or  more, 
and  keeps  up  high  for  several  days,  coming  down  slowly  to  its  former 
level.  In  many  cases,  however,  the  onset  is  insidious,  with  vague  pains 
in  the  chest,  or  altogether  painless.  We  often  find  signs  of  dry  pleurisy 
or  of  an  effusion  in  phthisical  patients  without  any  history  of  an  acute 
onset. 

The  physical  signs  of  localized  dry  pleurisy  are  friction  sounds  and 
a  decrease  in  the  intensity  of  the  breath  sounds  over  the  affected  area. 
The  friction  sounds  are  shuffling  in  character,  at  times  creaking  or 
squeaking.  In  some  cases  they  greatly  simulate  crepitation  or  even 
rhonchi.  The  criteria  for  their  differentiation  given  in  text-books — 
persistence  after  cough,  superficial  localization,  and  increase  on  press- 
ure with  the  stethoscope,  etc. — are  often  inadequate  to  distinguish 
them.  Perhaps  the  fact  that  they  are  heard  during  both  phases  of 
respiration  is  the  best  distinguishing  sign,  but  even  this  is  at  times 
misleading. 

When  effusions  occur  the  breath  sounds  are  altogether  absent  or 
very  feeble,  and  flatness  is  found  on  percussion.    Small  effusions  are 


400  COMPLICATIONS  OF  PHTHISIS 

more  easily  discovered  in  the  left  side  when  finding  that  Traube's 
semilunar  space  is  dull.  But  in  chronic  phthisis  this  is  not  to  be 
taken  without  qualification  because  thickened  pleura  in  that  area  may 
give  dulness.  On  the  other  hand,  small  effusions  are  often  found  in 
the  left  side  leaving  Traube's  space  resonant.  Grocco's  triangle  of 
paravertebral  dulness  is  made  out  in  most  cases.  Localized  empyemata 
are  best  made  out  by  the  aid  of  skiagraphy. 

Serous  effusions  may  be  absorbed  within  a  few  weeks,  but  in  many 
cases  they  remain  for  months  or  indefinitely. 

The  effects  of  pleural  effusions  on  the  course  of  phthisis  have  been 
extensively  discussed  of  late.  In  former  times  they  were  considered  very 
unfavorable.  Lately  several  authors  have  pointed  out  that  an  effu- 
sion into  the  pleura  may  be  rather  of  good  augury,  collapsing  the  lung 
and  bringing  it  to  rest,  as  we  attempt  to  do  when  inducing  artificial 
pneumothorax.  It  appears,  however,  that  the  whole  problem  is  not 
so  much  about  the  effusion,  excepting  when  it  is  very  copious  and 
menacing,  which  is  rather  rare,  but  depends  on  the  underlying  pul- 
monary lesion.  When  the  latter  is  unilateral,  not  extensive,  and  shows 
no  tendency  to  progressive  activity,  an  effusion  usually  has  no  influence 
at  all.  These  effusions  appear  and  disappear  without  injuring  the 
patient.  But  when  the  lesion  is  active,  extensive  and  progressive,  a 
pleural  effusion  may  do  considerable  harm;  especially  is  this  true 
when  the  effusion  occurs  in  the  side  of  the  chest  harboring  the  minor 
lesion,  while  in  the  opposite  side  there  is  extensive  cavitation,  etc. 

Empyema. — Empyema  may  occur  during  any  stage  of  phthisis, 
though  it  is  a  comparatively  rare  complication.  It  seems  to  me  that 
in  most  cases  in  which  it  occurs  there  was  a  spontaneous  pneumo- 
thorax which  was  not  recognized.  Of  late  it  is  frequently  encountered 
in  the  form  of  pyopneumothorax  after  the  induction  of  therapeutic  pneu- 
mothorax. It  may  be  localized,  interlobar,  and  then  it  is  very  difficult 
of  diagnosis,  the  symptoms  passing  as  part  and  parcel  of  the  phthisical 
process.  The  microorganisms  found  in  the  pus  include  tubercle  bacilli, 
•pneumococci,  and  the  pyogenic  microorganisms.  The  kind  of  micro- 
organism found  has  no  influence  on  the  symptomatology,  course,  and 
outcome  of  this  complication. 

The  onset  of  empyema  during  the  course  of  phthisis  is  usually 
insidious.  In  fact  many  cases  are  altogether  latent  and  discovered 
accidentally,  or  with  the  a;-rays.  The  latency  is  best  explained  by  the 
fact  that  the  usual  symptoms  of  empyema  are  such  as  are  met  with 
during  the  course  of  phthisis  without  this  complication.  Moreover, 
occurring  as  it  does  in  the  more  or  less  advanced  stages  of  the  disease, 
the  purulent  effusion  takes  place  into  a  pleura  which  is  adherent,  and 
therefore  the  process  remains  limited.  In  fact  it'  is  xery  frequently 
sacculated.  Because  the  lung  has  been  damaged  by  the  tuberculous 
process,  it  has  lost  a  great  part  of  its  expansive  power,  and  will  not 
easily  reexpand  after  removal  of  the  pus,  and  the  prognosis  is  thus 
very  unfavorable. 


SPONTANEOUS  PNEUMOTHORAX  401 

Empyema  is  one  of  tlie  most  dangerous  complications  of  phthisis. 
Spontaneous  absorption  never  occurs.  Operations  for  the  removal 
of  the  pus  are  very  unsatisfactory.  The  result  is  usually  that  the 
fever,  cachexia,  and  amyloid  degeneration  of  the  viscera  carry  off  the 
patient  sooner  or  later.  I  have  had  2  cases  in  which  empyemata  have 
opened  into  the  bronchi  and  the  pus  was  expectorated.  The  patients 
were  "cured"  of  the  empyema,  but  the  tuberculous  process  proceeded 
its  course. 

Gangrene  of  the  Lungs. — This  is  an  exceedingly  rare  complication 
of  phthisis;  it  is  more  often  found  in  cases  of  bronchiectasis,  especially 
in  old  subjects.  Considering  that  mixed  infection  is  very  frequent  in 
phthisis,  although  the  contaminating  microorganisms  are  not  respon- 
sible for  most  of  the  symptoms  of  the  disease,  it  is  surprising  that 
putrefactive  germs  should  but  rarely  take  root  in  phthisical  lungs. 
When  occurring  it  is  soon  recognized  by  the  fetid  breath  and  expectora- 
tion. But  not  all  phthisical  patients  with  fetid  sputum  have  gangrene 
of  the  lung.  Sputum  retained  in  tuberculous  cavities  may  become 
fetid.  But  in  such  cases  the  malodorous  expectoration  lasts  only  for 
a  few  days  or  weeks  and  sooner  or  later  assumes  the  odor  usually  met 
in  phthisis.  Its  odor  also  is  different  from  that  of  gangrenous  sputum 
— it  is  of  a  sweetish  and  nauseating  character,  while  in  gangrene  it 
is  pungent  and  actually  suffocating.  The  constitutional  symptoms 
in  gangrene  are  characteristic:  The  temperature  is  raised  high,  the 
patient  passes  into  a  septic  state  with  acute  asthenia,  and  succumbs 
rapidly.  In  afebrile  cases  of  phthisis  a  sudden  rise  in  the  temperature 
accompanied  by  fetid  sputum  is  a  sure  indication  of  complicating 
gangrene  of  the  lung. 

Spontaneous  Pneumothorax. — This  is  the  most  frightful  complica- 
tion of  phthisis.  It  is  of  more  significance  than  copious  hemorrhage 
because  the  latter  only  terrifies  the  patient  and  its  ultimate  prognosis 
is  usually  favorable,  as  we  have  already  shown,  but  pneumothorax  is 
deadly  and  the  victim  is  justified  in  his  apprehension  that  the  collapse 
and  agonizing  dyspnea  are  indications  that  he  is  breathing  his  last. 
From  West's^  statistics  it  appears  that  70  per  cent,  of  patients  attacked 
by  pneumothorax  die,  and  in  phthisis  the  proportion  is  even  higher. 

"  To  anyone  carefully  examining  the  lungs  of  patients  dying  of  acute 
phthisis,"  says  Williams,-  "the  marvel  is  not  that  pneumothorax  should 
occur,  but  that  it  should  not  do  so  more  frequently,  for  it  is  not  un- 
common to  see  what  appears  to  be  several  abscesses  immediately 
underlying  the  visceral  pleura,  and  apparently  ready  to  burst." 
Chronic  lesions  are  usually  well  protected  against  bursting  into  the 
pleura  by  more  or  less  massive  adhesions,  and  pneumothorax  mostly 
occurs  in  acute  cases  in  which  the  process  extends  quickly  before 
adhesions  can  form. 


^  Dis.  of  the  Organs  of  Respiration,  London,  1909,  p.  837. 
2  Pulmonary  Consumption,  London,  1887,  p.  206. 
26 


402  COMPLICATIONS  OF  PHTHISIS 

Frequency. — The  frequency  of  this  compHcation  varies  with  the 
character  of  the  chnical  material.  It  is  not  very  frequent  in  hospitals 
for  advanced  cases  because  only  old  cases  are  admitted  in  whom  pleural 
adhesions  prevent  its  occurrence.  According  to  Powell,  about  6  per 
cent,  of  the  fatal  cases  of  phthisis  at  the  Bromptom  Hospital,  in  Lon- 
don, succumbed  with  pneumothorax;  Williams  found  10  per  cent,  and 
Weil  even  13  per  cent.  In  many  cases  sudden  death  in  phthisis  is 
caused  by  this  complication,  though  it  may  not  have  been  recognized. 
At  the  Montefiore  Home  we  meet  with  about  a  dozen  cases  annually 
among  300  treated.  As  has  been  pointed  out  by  Sir  Douglas  Powell, 
the  lesion  is  more  likely  to  occur  in  the  left  than  on  the  right  side. 
From  a  collection  of  234  cases  reported  by  Louis,  Walshe,  West,  and 
himself,  he  finds  that  in  95  it  was  on  the  right  and  in  139  on  the  left 
side.  Powell  attributes  it  to  the  greater  frequency  with  which  the 
left  lung  becomes  the  seat  of  tuberculous  disease. 

Symptoms. — The  onset  is  sudden,  unexpected.  The  patient  has 
known  that  he  is  tuberculous  for  some  time,  and  may  have  been  assured 
that  his  prospects  for  an  ultimate  recovery  are  good.  But  suddenly, 
like  a  thunderbolt  out  of  a  clear  sky,  after  a  fit  of  coughing,  some  slight 
exertion,  or  without  any  exciting  cause  at  all,  he  is  seized  with  a  sharp 
agonizing  pain  in  the  chest,  he  feels  as  if  "something  has  given  way," 
or  as  if  something  cold  is  trickling  down  his  side.  He  at  once  sits  up 
in  bed  holding  his  hand  fast  over  the  affected  side,  gasping  for  breath. 
Acute  distressing  dyspnea,  cyanosis,  a  small,  rapid  and  feeble  pulse, 
cold,  clamy  extremities  and  other  phenomena  of  collapse  soon  make 
their  appearance.  The  facial  expression  is  that  of  profound  agony, 
the  eyes  prominent,  the  lips  livid  and  the  forehead  clammy.  The 
respirations  are  frequent — fifty  or  more  per  minute,  and  superficial. 
The  temperature,  which  may  have  been  elevated  for  some  time, 
suddenly  drops  to  below  normal  and  the  cough,  which  may  have  been 
annoying  before  the  accident  occurred,  ceases  for  a  time;  perhaps 
because  of  the  pain  the  patient  restrains  himself. 

In  very  acute  cases  the  patient  may  expire  within  a  few  hours  as  a 
result  of  profound  shock,  dyspnea,  and  heart  failure.  Many  of  the 
cases  of  sudden  death  in  phthisis  are  due  to  this  cause.  But  in  most 
cases  the  circulation  adapts  itself  by  degrees  to  the  altered  conditions 
of  the  thoracic  viscera,  the  dyspnea  is  ameliorated,  the  temperature 
rises  to  above  normal  and  the  patient  feels  somewhat  relieved,  the  air 
hunger  not  being  as  acute  as  at  the  onset,  though  he  still  breathes 
forty  or  more  times  per  minute,  and  is  still  cyanosed.  Within  a  few 
days,  usually  between  the  third  and  fifteenth  day  an  eft'usion  of  fluid 
into  the  affected  pleura  is  found,  hydropneumothorax,  or  pyopneumo- 
thorax. 

The  size  of  the  perforation  into  the  lung  has  but  little  influence  on 
the  acuity  of  the  distress — a  small  opening  the  size  of  a  pinhead  may 
permit  the  entry  of  sufficient  air  into  the  pleura  to  collapse  the  lung 
completely  and  to  displace  the  thoracic  and  abdominal  organs  just  as 


PLATE  XIV 


Fig.  1 


Fig.  2 


Dense  infiltration  of  the  upper  half  of 
the  left  lung  with  displacement  of  the 
heart  to  the  left.  Right  lung  emphyse- 
matous. 


From  same  patient  as  Fig.  1.  Spon- 
taneous pneumothorax,  air  filling  left 
pleural  cavity,  and  displacing  the  heart 
to  the  right. 


Fig.  3 


Fig.  4 


Pneumothorax  in  right  pleura  extending 
in  a  thin  layer  of  air  from  the  diaphragm 
to  the  apex.  Right  lung  slightly  collapsed 
and  presents  consolidation  at  its  lower 
third.  The  rest  appears  studded  with 
cavities  and  calcified  nodules.  Lower 
half  of  left  lung  emphysematous;  upper 
half  nodular  infiltration,  especially  at 
axilla.  Heart  and  trachea  displaced  to 
the  right. 


Hydropneumothorax  in  the  right  pleura. 


SPONTANEOUS  PNEUMOTHORAX  403 

well  as  a  larger  one.  In  fact,  in  some  quickly  fatal  cases  only  a  small 
opening  or  slit  is  found  at  autopsy,  while  in  others  with  large  openings 
little  distress  is  seen,  healing  is  rapid,  and  the  patient  may  last  for 
months.  At  the  necropsy  it  is  found  that  the  opening  is  usually  small, 
linear,  slit-like,  and  occasionally  circular,  at  times  attaining  the  size 
of  a  dime.  In  some  cases  there  are  two  or  even  three  perforations. 
.  Varieties  of  Pneumothorax. — It  is  of  clinical  significance  whether  the 
perforation  closes  speedily  and  no  more  air  or  pus  can  pass  into  the 
pleural  cavity,  thus  allowing  absorption  of  the  air.  The  symptoms, 
prognosis,  and  treatment  depend  mainly  on  this  point.  There  are 
described  in  text-books  three  varieties  of  pneumothorax — ope/?,  closed, 
and  valvular.  In  the  open  variety  there  is  a  patent  opening  which 
permits  air  to  pass  in  and  out  of  the  pleural  cavity  and  the  tension 
within  the  affected  pleura  is  equal  to  that  of  the  external  air.  In  the 
closed  variety  the  perforation  has  healed,  and  the  air  in  the  pleural 
cavity  may  be  absorbed  sooner  or  later,  as  is  the  case  with  induced 
therapeutic  pneumothorax,  wdth  or  without  the  development  of  an 
effusion  which  is  generally  serous.  In  the  valvular  variety,  during 
inspiration  or  cough  air  enters  freely  into  the  pleura,  but  is  prevented 
from  coming  out  again  during  expiration  by  a  valve  or  contraction 
of  the  slit.  The  result  is  that  the  tension  within  the  pleural  cavity 
becomes  very  high  and,  pushing  the  mediastium  to  the  opposite 
unaffected  side,  causes  distressing  dyspnea,  cyanosis  and  heart 
failure  till  the  patient  is  no  longer  able  to  cope  with  the  situation 
and  succumbs. 

This  interpretation  of  pneumothorax  has  of  late  been  questioned  by 
West,  Bard,  Castaigne  and  others.  West  says:  "All  pneumothorax  is 
at  first  valvular,  at  any  rate  more  or  less,  i.  e.,  the  air  finds  more  or 
less  difficulty  on  expiration.  Thus  the  pleura  becomes  more  and  more 
full  of  air  and  the  lungs  more  and  more  compressed,  and  this  obviously 
tends  to  close  the  hole  more  or  less  completely.  When  the  hole  is  of 
ordinary  size,  it  will  becoE^e  patent  on  inspiration  and  thus  admit  air, 
but  only  so  long  as  the  pressure  in  the  pleura  is  less  than  that  of  the 
air  in  the  air  tubes.  As  soon  as  the  pressure  on  the  two  sides  is  equal, 
no  more  air  cau  enter,  and  the  hole  remains  closed.  If  the  edges 
cohere,  the  hole  will  remain  permanently  closed ;  if  not,  as  soon  as  the 
pressure  in  the  pleura  is  diminished,  as  it  may  be  by  paracentesis,  the 
orifice  may  open  again  into  the  pleura.  This  is  the  explanation  in 
many  cases  of  the  return  of  dyspnea  after  paracentesis." 

As  has  been  pointed  out  by  Sir  R.  Douglass  Powell,  the  displace- 
ment of  the  mediastinum  is  not  necessarily  due  to  the  pressure  exerted 
by  the  air  in  the  pleural  cavity.  His  manometric  measurements 
have  revealed  no  positive  pressure  in  pneumothorax.  From  his  inves- 
tigations he  is  inclined  to  believe  that  the  dislocation  of  the  heart  is 
due  to  the  unopposed  traction  exerted  by  the  elastic  unaffected  lung. 
Because  they  are  no  longer  held  up  by  the  elasticity  of  the  lung,  the 
diaphragm  and  the  abdominal  viscera  sink  downward. 


404  COMPLICATIONS  OF  PHTHISIS 

Partial  Pneumothorax. — In  old  chronic  cases  of  phthisis  we  meet  with 
partial  pneumothorax  in  which  there  is  a  perforation  into  the  pleural 
cavity,  but  owing  to  dense  adhesions  the  air  is  only  filling  up  a  limited 
pouch  at  a  place  where  the  pleural  sheets  are  not  adherent.  The  onset 
is  less  acute  and  the  symptoms  of  collapse  are  usually  absent.  The 
patient  may  have  some  pain  in  the  chest,  dj^spnea,  etc.,  but  these 
attract  little  attention  in  a  disease  like  phthisis  in  which  these  symp- 
toms are  so  frequent  without  the  occurrence  of  pneumothorax.  Careful 
physical  examination  may  disclose  signs  of  the  condition,  but  it  is 
easier  to  find  it  out  with  the  aid  of  skiagraphy.  I  have  seen  cases  in 
which  skiagraphy  could  not  decide.  It  is  often  mistaken  for  a  large 
cavity,  especially  when  it  is  localized  over  an  apex,  but  even  in  the  lower 
parts  of  the  chest  it  may  exquisitely  simulate  pulmonary  excavation. 

Latent  Pneumothorax. — ^At  times  we  meet  in  tuberculous  patients  a 
pneumothorax  without  a  history  of  an  acute  onset  with  pain,  dyspnea, 
collapse,  etc.  In  some  of  these  cases  careful  inquiry  elicits  a  history 
pointing  to  a  subacute  onset,  but  such  symptoms  are  quite  com- 
mon in  chronic  phthisis  without  this  complication.  In  one  case 
admitted  to  the  hospital  we  found  complete  collapse  of  the  lung  and 
we  at  first  suspected  an  artificial  pneumothorax,  produced  before 
admission,  but  it  turned  out  to  be  a  latent  case. 

In  chronic  phthisis  we  also  meet  with  cases  in  which  there  is  a 
sudden  onset  with  all  the  symptoms  of  this  accident,  but  physical 
examination  fails  to  reveal  any  of  the  signs.  The  French  call  it  'pneu- 
mothorax niuet,  the  silent  form.  In  these  cases  the  signs  do  appear, 
however,  within  a  few  days.  In  one  of  my  cases  of  this  character  a 
radiographic  plate  showed  that  the  air  was  filling  the  thoracic  cavity 
for  an  inch  or  two  along  the  axillary  line.  In  others  there  was  an 
interlobar  air  pouch.  These  forms  are  best  diagnosticated  with  the 
a,'-rays. 

Double  Pneumothorax. — Double  pneumothorax  has  been  met  with 
in  phthisis  on  exceedingly  rare  occasions.  It  is  incompatible  with 
life.  But  D.  Hellin^  and  R.  Staehelin^  mention  cases  which  lasted  for 
days. 

Physical  Signs. — The  affected  side  of  the  chest  is  larger— in  the 
maximum  inspiratory  position;  the  shoulder  raised,  the  intercostal 
spaces  obliterated,  tense  and  tender  to  the  touch.  While  the  number 
of  respirations  is  fifty  or  more  per  minute,  movements  of  the  thorax 
are  seen  only  in  the  unaffected  side,  while  the  affected  side  is  fixed, 
almost  immobile.  In  the  vast  majority  of  cases  the  apex  beat  cannot 
be  seen,  but  when  visible  it  is  found  at  the  left  axillary  line  in  right- 
sided  pneumothorax  and  at  the  xyphoid  cartilage  or  even  beyond 
it  in  left-sided  perforations.  Vocal  fremitus  is  abolished  over  the 
affected  side. 

Instead  of  the  dull  note  which  was  found  before  the  accident,  the 

'  Mitt.  a.  d.  Grcnzgeb.  d.  Med.  u.  Chir.,  1907,  xvii,  414. 

2  Mohr  and  Staehelin's  Handbuch  der  iuneren  Medizin,  Berlin,  1914,  ii,  756. 


PLATE  XV 


Fig.  1 


Fig.  2 


Left  pleura  filled  with  air,  but  large 
cavity  with  dense  walls  under  second  and 
third  interspace  did  not  collapse.  Nodular 
infiltrations  throughout  right  lung.  Di- 
lated bronchi  and  enlarged  glands  in  hilus 
region. 


Complete  pneumothorax  of  right 
thoracic  cavity  pushing  mediastinum  to 
the  left  and  compressing  the  left  lung. 
Trachea  visible  as  markedly  displaced  to 

left. 


Fig.  3 


Fig.  4 


Old  fibroid  phthisis  with  extensive 
involvement  of  the  left  lung  and  pleura. 
Spontaneous  pneumothorax  of  right  pleura. 


Diffuse  tuberculous  process  all  over 
both  lungs;  marked  peribronchial  infil- 
trations, and  calcified  glands  along  the 
hilus.  The  apex  is  infiltrated  and  adherent 
in  the  left  side;  below  the  clavicle  there  is 
a  circumscribed  pneumothorax,  which  on 
physical  exploration  gave  signs  of  a  cavity. 
The  lower  half  of  the  left  pleura  is  thick- 
ened, which  cannot  be  differentiated  in 
the  radiogram  from  fluid. 


SPONTANEOUS  PNEUMOTHORAX  405 

affected  side  emits  a  hyperresonant,  sometimes  a  tympanitic  note, 
depending  on  the  tension  of  the  air  within  the  pleural  cavity.  By 
comparison,  the  unaffected  side  appears  to  emit  a  defective  or  dull 
note.  In  cases  in  which  the  upper  part  of  the  pleura  is  adherent  and 
does  not  collapse,  the  apex  is  dull  or  "boxy"  on  percussion.  When 
later  fluid  makes  its  appearance  in  the  pleural  cavity,  we  elicit  a  flat 
note  over  the  lower  part  of  the  chest  and  the  flatness  changes  its  level 
with  the  change  in  the  patient's  position.  Shifting  dulness  is  pathog- 
nomonic of  air  and  fluid  in  the  pleural  cavity.  Displacement  of  the 
thoracic  and  abdominal  viscera  can  be  made  out  more  or  less  easily  by 
percussion.  In  right-sided  lesions  the  liver  dulness  disappears  alto- 
gether, or  is  displaced  downward,  and  the  heart  is  shifted  to  the  left, 
even  as  far  as  the  axillary  line;  in  left-sided  pneumothorax  the  heart 
dulness  may  be  completely  absent,  or  displaced  to  the  right,  and  the 
splenic  dulness  may  also  be  absent.  In  fact  the  spleen  and  the  liver 
may  be  felt  distinctly  low  in  the  abdomen.  The  displacement  of  the 
heart  may  be  noted  a  few  minutes  after  the  occurrence  of  the  accident. 

We  may  also  elicit  various  metalic  or  amphoric  notes  on  percussion, 
especially  with  a  coin  placed  over  the  chest  and  tapping  it  with  a  stick 
or  pencil,  while  listening  with  the  naked  ear  or  stethoscope  over  the 
opposite  side  of  the  chest.  Biermer's  and  Wintrich's  signs,  as  well  as 
cracked-pot  resonance  may  be  elicited  in  many  cases. 

Auscultation  shows  complete  absence  of  breath  sounds  over  the 
affected  side  of  the  chest  in  cases  in  which  the  opening  is  small  or 
closed  and  the  lung  is  completely  collapsed.  When  the  upper  parts  of 
the  pleura  are  adherent,  the  auscultatory  phenomena  of  the  original 
lung  lesion  are  audible,  but  below  no  sounds  at  all  are  heard.  But  in 
most  cases  there  are  heard  amphoric  breath  sounds  at  some  point 
between  the  shoulder-blades.  Exceptionally  we  meet  with  a  case  of 
pneumothorax  in  which  the  voice  and  breath  sounds  are  audible  in  an 
exaggerated  form  all  over  the  affected  side.  When  the  opening  into 
the  lung  is  large,  permitting  the  passage  of  air  from  the  bronchi  into 
the  pleural  cavity,  we  may  hear  an  exquisite  variety  of  amphoric 
breathing  or  metallic  sounds  which  are  characteristic.  The  voice 
sounds,  as  well  as  the  cough,  may  also  have  a  metallic  echo. 

The  splashing  or  succussion  sound  is  audible  at  a  distance  in  many 
cases,  and  the  patients  themselves  are  annoyed  by  it.  Some  patients 
know  how  to  jerk  their  bodies  to  produce  it  to  the  best  advantage. 
I  have  had  patients  in  whom  the  succussion  sound  was  the  only  indica- 
tion of  fluid  in  the  thorax,  all  other  signs  being  absent  because  of  the 
depression  of  the  diaphragm,  the  result  of  the  pressure  exerted  by  the 
tension  of  the  air  in  the  pleura.  It  is  an  excellent  proof  of  the  existence 
of  air  and  fluid  in  the  pleura.  It  is  stated  that  it  may  be  elicited  in 
the  stomach  and  colon,  but  I  have  not  met  with  a  case  in  which 
this  vitiated  a  diagnosis. 

Metallic  Tinkling. — A  clear  musical  note,  heard  at  intervals  on  listen- 
ing over  a  hydropneumothorax,  resembling  a  drop  of  water  falling  into 


406  COMPLICATIONS  OF  PHTHISIS 

a  reverberating  vessel,  maj^  be  heard  in  some  cases.  At  times  it 
is  only  heard  after  cough.  It  is  apparently  not  due  to  the  falling  of  a 
drop  at  all,  but  to  a  rale  produced  in  some  portion  of  the  lung  which 
acquires  a  metallic  character  by  reverberation. 

Diagnosis. — The  diagnosis  of  pneumothorax  has  undergone  quite 
some  changes  within  recent  years  since  we  have  had  an  opportunity 
to  study  this  condition  produced  artificially  in  tuberculous  patients 
for  therapeutic  purposes,  and  also  since  we  employ  skiagraphy  for  the 
purpose  of  examining  the  chest.  We  now  have  explanations  for  some 
phenomena  which  were  formerly  obscure,  and  we  know  that  certain 
signs  formerly  considered  pathognomonic  of  pneumothorax,  are  not  at 
all  invariable  accompaniments  of  the  disease. 

In  the  usual  case  of  pneumothorax  dm-ing  the  course  of  phthisis,  the 
sudden  onset  of  urgent  dyspnea,  pain  in  the  chest,  collapse,  etc., 
coupled  with  physical  signs  of  pulmonary  collapse,  suffice  to  establish 
the  diagnosis.  But  there  are  many  sources  of  error.  We  may  have 
pneumothorax  without  any  of  these  acute  symptoms,  as  has  been 
already  stated.  In  fact,  since  the  a;-rays  have  been  employed  the 
number  of  latent  and  silent  cases  of  pneumothorax  has  enormously 
increased.  On  the  other  hand,  we  meet  in  phthisis  cases  of  acute 
dyspnea,  pain,  and  even  collapse  not  due  to  this  accident.  Especially 
difficult  are  the  cases  of  partial  pneumothorax,  because  the  medias- 
tinum is  not  displaced,  and  a  thickened  pleura  may  obscure  the 
tympany  and  the  absent  or  amphoric  breath  sounds  may  be  otherwise 
interpreted.  At  times  it  is  very  difficult  to  differentiate  a  partial 
pneumothorax  from  a  large  pulmonary  cavity,  and  before  the  advent 
of  skiagraphy  mistakes  of  this  kind  were  more  frequently  made  than  at 
present.  The  differentiation  is  usually  of  practical  value,  because 
the  prognosis  in  cases  with  large  excavations  is  very  unfavorable, 
while  with  a  localized  pneumothorax  it  is  more  hopeful. 

Even  in  cases  with  complete  collapse  of  the  lung,  tympany  may  not 
be  elicited  on  percussion,  as  we  have  learned  lately  in  cases  of  artificial 
pneumothorax.  It  appears  that  it  all  depends  on  the  tension  of  the 
air  within  the  plem-al  cavity.  In  hydropneumothorax,  tympany  is 
found  when  there  is  but  little  fluid  and  considerable  air;  but  when 
the  eftusion  is  copious  we  get  flatness  which  disappears  when  the  fluid 
is  aspirated,  provided  the  pleura  is  not  too  thick. 

The  position  of  the  heart  is  usually  of  assistance  in  deciding  whether 
we  deal  with  a  large  cavity  or  a  pneumothorax:  In  the  former  it  is 
displaced  toward  the  affected  side,  while  in  the  latter  it  is  moved 
away  from  it.  But  even  here  there  are  many  important  exceptions 
owing  to  previous  pleural  adhesions,  etc.  Skiagraphy  usually  decides, 
but  not  always. 

The  signs  obtained  on  auscultation  dift'er  very  much  in  cases  of  open 
as  compared  with  closed  pneumothorax,  and  in  the  latter  cases  it 
depends  on  whether  the  lung  is  completely  or  only  partially  collapsed. 
A  closed  pneumothorax  with  complete  collapse  is  silent;  no   breath 


PLATE  XVI 


Fig.  1 


Spontaneous  pneumothorax  complicated  by  hydro-  or  pyopneumopericardium. 
Shows  pneumopericardium  and  beginning  effusion  into  pericardium;  pneumothorax  in 
left  pleura,     p,  pericardium;  pn,  pneumothorax;  fl,  fluid  in  chest;  h,  heart. 


Fig.  2 


Hydropneumothorax;  pneumopericardium;  patient  lying  on  the  left  side.  The 
fluid  in  the  left  pleura  shifted  to  the  axillary  side.  Air  in  the  right  side  of  the 
pericardium  is  plainly  visible.     (Case  of  Dr.  A.  Meyer.) 


SPONTANEOUS  PNEUMOTHORAX  407 

sounds  at  all  are  audible  as  a  rule.  At  times  we  perceive  some  bronchial 
breathing  in  the  interscapular  space  emitted  from  the  bronchi  near 
the  spine.  In  the  open  variety  we  usually  hear  amphoric  breathing  of 
an  exquisite  type.  In  many  cases  of  phthisis,  in  which  the  pleura  is 
free  all  over,  it  is  adherent  at  its  upper  third,  over  the  site  of  the  main 
lesion,  and  does  not  collapse  at  that  place,  and  we  obtain  the  breath 
sounds  and  rales  peculiar  to  the  diseased  lung. 

The  breath  sounds  often  audible  over  a  completely  collapsed  lung 
were  formerly  attributed  to  some  opening  into  a  bronchus  allowing 
air  to  pass  in  and  out  of  the  pleura.  We  now  know  that  this  is  not 
always  the  case  because  in  artificial  pneumothorax,  where  an  opening 
into  the  lung  is  positively  excluded,  we  often  perceive  the  same  acoustic 
phenomena.  It  seems  that  the  air  in  the  pleural  cavity  is  capable 
of  transmitting  the  sounds  in  the  bronchi  when  in  a  certain  condition 
of  tension. 

The  bell  sound  is  almost  invariably  heard  in  all  cases  in  which  the 
effusion  is  not  too  thick,  as  in  some  cases  of  pyopneumothorax.  It 
is  easily  elicited  by  placing  a  coin  over  the  anterior  surface  of  the 
thorax  and  percussing  it  with  another  while  auscultating  posteriorly 
or  in  the  axilla.  A  clear,  ringing,  bell-like  sound,  which  is  character- 
istic, is  heard.  But  exceptionally  it  is  also  heard  over  large  cavities, 
or  even  a  dilated  stomach.  It  is  often  absent  in  pneumothorax;  but 
when  heard  it  is  of  significance,  showing,  as  it  does,  air  and  fluid  in  the 
pleural  cavity.  We  may  hear  it  only  with  the  patient  in  the  horizontal 
position.  In  some  it  appears  only  after  some  of  the  fluid  has  been 
aspirated. 

A  positive  diagnosis  of  pneumothorax  can  be  made  when  one  is 
alert  and  looks  for  it  in  every  suspicious  case.  In  most  cases  the 
abrupt  onset  of  the  urgent  symptoms  and  the  physical  signs  suffice. 
In  doudtful  cases  the  Roentgen  rays  decide  easily  and  speedily. 

A  rare  complication  of  pneumothorax,  the  spontaneous  as  well 
as  the  artificial  varieties,  is  pneumopericardium — air  entering  the 
pericardial  sac.  We  then,  have  instead  of  the  cardiac  dulness,  hyper- 
resonance  or  tympany,  sometimes  cracked-pot  sound.  On  ausculta- 
tion we  hear  that  the  heart  sounds  are  extraordinarily  intensified,  and 
a  splashing  sound  is  audible,  or  a  succussion  sound,  synchronous  with 
the  systole.  In  the  case  observed  by  the  author  there  was  also  a 
metallic  tinkle  and  a  friction  fremitus,  especially  when  the  patient  bent 
his  body  forward.  Similar  cases  have  been  reported  by  Wenckebach,^ 
Cowan,-  Harrington  and  Riddell,  and  Alfred  Meyer.^  With  the  aid 
of  skiagraphy  the  diagnosis  offers  no  difficulty,  as  can  be  seen  from  the 
skiagram  (Plate  XVI)  of  Dr.  Meyer's  case. 

Prognosis. — On  the  whole,  the  prognosis  of  spontaneous  pneumo- 
thorax is  decidedly  gloomy.    Occurring,  as  it  does,  in  patients  who  are 

1  Ztschr.  f.  klin.  Med.,  1910,  Ixxi,  402. 

2  Quarterly  Jour,  of  Med.,  1914,  vii,  165. 

3  Medical  Record,  1915,  Ixxxviii,  991. 


408  COMPLICATIONS  OF  PHTHISIS 

usually  doomed  because  of  the  condition  of  the  lungs,  this  accident 
but  accelerates  the  inevitable.  In  very  acute  cases  the  patients 
succumb  within  a  few  days,  and  90  per  cent,  die  within  a  month.  An 
open  pneumothorax,  permitting  the  entry  of  the  contents  of  pulmon- 
ary cavities  into  the  pleura  is  almost  invariably  fatal  sooner  or  later. 

While  there  have  been  reported  cases  of  hydro-  and  pyopneumo- 
thorax that  have  survived  for  years  and  some  in  which  the  fluid  has 
been  absorbed,  they  are  exceedingly  rare  and  in  all  cases  that  I  have 
seen  the  patients  succumbed  within  one  year  after  the  onset  of  the 
complication. 

Conditions  are  somewhat  different  with  the  closed  cases  of  pneu- 
mothorax, also  the  partial  variety.  They  usually  occur  in  patients 
with  but  slight  tuberculous  lesions  and  with  good  resisting  power. 
As  long  as  there  is  no  communication  with  a  tuberculous  cavity,  and 
the  pleura  is  not  infected,  as  is  the  case  with  artificial  pneumothorax, 
the  air  in  the  pleura  may  in  time  be  absorbed.  In  fact,  it  was  these 
rare  cases  of  collapse  of  the  lung  and  the  resulting  amelioration  of  the 
sjTxiptoms  of  phthisis,  which  suggested  the  idea  of  therapeutic  pneumo- 
thorax, of  which  we  will  speak  later  on. 

Laryngeal  Tuberculosis. — The  frequency  of  this  complication 
during  the  course  of  phthisis  has  been  differently  stated  by  various 
authors.  The  proportion  varies  from  5  to  50  per  cent.  Harold  Bar- 
well  found  at  the  Mount  Vernon  Sanatorium  11.69  per  cent,  among 
1541  tuberculous  patients;  Brandenburg,  9.16  per  cent.;  John  B. 
Hawes,^  only  8  per  cent,  among  1245  patients.  Even  sanatoriums, 
which  do  not  admit  patients  with  lar\Tigeal  complications,  have 
many  with  this  disorder.  Thus  at  Otisville,  N.  Y.,  Julius  Dworetzky^ 
found  that  25.6  per  cent,  had  laryngeal  tuberculosis.  It  seems  that  the 
proportion  found  depends  on  the  zeal  displayed  by  the  larjmgologists 
looking  for  it.  Percy  Kidd-^  found  that  50  per  cent,  of  fatal  cases  of 
phthisis  showed  tuberculous  laryngitis  at  the  autopsy,  and  of  these 
only  20  to  50  per  cent,  were  recognized  during  life.  The  estimate  that 
one  out  of  three  patients  "uith  active  phthisis  has  a  laryngeal  lesion, 
appears  to  be  correct. 

Laryngeal  tuberculosis  spells  phthisis;  primary  tuberculosis  of  this 
organ  is  so  exceedingly  rar/e  as  to  constitute  a  medical  curiosity.  It 
is  more  frequent  among  males  than  among  females,  the  proportion 
being,  according  to  IMorel  ^Mackenzie,  2.7  of  the  former  to  1  of  the 
latter.  The  reason  for  this  disparity  is  that  men  are  altogether  more 
liable  to  throat  affections,  probably  because  of  the  abuse  of  tobacco, 
alcohol,  and  exposm'e  to  U'ritation  by  dust  at  their  occupations.  It  is 
also  likely  to  be  more  severe  in  men  than  in  women. 

Ssrmptoms. — These  depend  on  the  location  of  the  lesion  in  the  lar^iix. 
Those  in  whom  the  interior  of  the  larynx  is  affected  do  not  suffer  as 

1  Boston  Med.  and  Surg.  Jour.,  1914,  clxxi,  19. 

2  Ann.  Otologj-,  Rhinology  and  Laryngology,  1914,  xxiii,  835. 

3  AUbutt's  System  of  Medicine,  v,  210. 


LARYNGEAL  TUBERCULOSIS  409 

much  as  those  whose  trouble  Hes  at  the  entrance  of  the  larynx.  The 
symptoms  are  few  in  number.  Hoarseness  is  present  in  all  in  whom 
the  interior  of  the  larynx  is  affected,  and  it  may  be  of  various  degrees, 
from  mild  tiring  of  the  voice  to  complete  aphonia.  On  the  other  hand, 
pain  is  more  frequent  when  the  entrance  of  the  larynx,  especially  the 
epiglottis  is  affected,  while  the  voice  may  in  these  cases  be  retained 
quite  well.  The  pain  may  be  spontaneous,  radiating  to  the  ear,  or  there 
may  be  a  sensation  of  tickling  which  provokes  cough.  In  advanced 
cases,  with  perichondritis,  deep  ulceration  of  the  epiglottis  and  col- 
lateral inflammatory  edema  of  the  parts,  the  pain  may  be  so  severe 
as  to  interfere  with  swallowing  food.  Usually  warm  fluids  and  solids 
cannot  be  passed.  The  dysphagia  may  be  so  severe  as  to  prevent 
swallowing  altogether.    I  have  seen  some  cases  in  which  swallowing 


Fig.  77. — Tuberculosis  of  the  larynx.     (Ballenger.) 

of  saliva  was  more  painful  than  that  of  food.  Local  external  tenderness 
is  rare.  Stridor  and  obstruction  of  respiration  are  comparatively  rare, 
but  they  do  occur  now  and  then. 

Diagnosis. — Considering  the  immense  prognostic  significance  of 
laryngeal  tuberculosis,  we  must  be  guarded  in  making  a  diagnosis 
of  this  complication.  Hoarseness  alone  is  insufficient  for  a  diagnosis 
because  it  may  be  absent  when  the  larynx  is  implicated  but  the  vocal 
cords  remain  in  good  shape;  or  it  may  be  present  in  a  patient  suffering 
from  phthisis,  yet  no  tuberculous  lesion  is  discoverable  in  the  larynx. 
This  is  seen  when  the  right  recurrent  laryngeal  nerve  is  implicated  in 
a  thickened  right  apical  pleural  lesion,  or  when  the  two  laryngeal 
nerves  are  pressed  upon  by  enlarged  tracheal  glands.  It  must  also  be 
borne  in  mind  that  simple  chronic  laryngitis  and  pharyngitis  are 
extremely  common  in  phthisical  subjects,  as  has  been  pointed  out  by 
Harold  S.  Barwell,^  and  they  may  cause  hoarseness  and  throat  discom- 

1  Lancet,  1909,  i,  1249. 


410  COMPLICATIONS  OF  PHTHISIS 

fort.  The  constant  coughing  and  the  irritation  of  the  sputum  passing 
through  the  larynx  may  produce  a  simple  laryngeal  catarrh. 

W.  Freudenthal'  urges  that  lasting  hoarseness  apparently  due  to 
simple  laryngitis,  and  seen  in  a  patient  who  is  not  presenting  symptoms 
of  alcoholism,  or  constitutional  diseases  as  gout  or  rheumatism,  should 
excite  suspicion  of  tuberculosis. 

The  diagnosis  of  tuberculous  laryngitis  is  quite  easy  when  there  are 
ulcerations  but  in  the  incipient  stage  it  appears  to  be  just  as  difficult 
as  the  diagnosis  of  incipient  pulmonary  tuberculosis.  Laryngologists 
usually  enumerate  the  laryngoscopic  signs  of  advanced  disease,  evi- 
dently because  they  mostly  see  advanced  cases. 

Some  authors  have  maintained  that  the  tuberculous  larynx  is  char- 
acterized by  pallor  of  the  mucous  membrane.  But  it  appears  that  pal- 
lor alone  is  insufficient  for  a  diagnosis  because  the  larynx  shares  the 
pallor  of  the  fauces  which  is  seen  in  most  tuberculous  patients;  it  is 
also  found  in  those  .who  suffer  from  severe  anemia  of  any  kind.  In 
fact,  there  are  just  as  many  red  and  congested  larynges  in  phthisical 
subjects  as  pale  ones. 

Paresis  of  the  vocal  cord  on  the  side  of  the  lung  lesion,  associated 
with  slight  chronic  laryngitis,  is  one  of  the  signs  of  incipient  tubercu- 
losis of  the  larynx,  according  to  many  authors,  notably  F.  Stern.^  He 
calls  this  the  "larynx  sign"  of  early  pulmonary  tuberculosis  and  advises 
direct  visual  inspection  to  detect  it  when  there  is  a  sensation  of  vague 
oppression  of  the  chest,  a  tendency  to  rheumatic  pains,  slightly 
irregular  breathing  or  gastric  disturbances.  The  entrance  to  the  throat 
is  moderately  red  and  the  paralyzed  vocal  cord  is  also  red.  There  is 
always  more  mucus  on  the  paretic  cord  than  on  the  other,  and  its 
inner  margin  is  usually  irregular  in  outline.  There  is  slight  hoarse- 
ness, particularly  at  night  and  the  patient  hawks  often  but  raises 
very  little  sputum  and  tubercle  bacilli  may  not  be  found  at  this  early 
stage. 

Minor,^  whose  opinion  is  of  value  because  he  could  follow  his  cases 
both  from  the  general  clinical,  and  the  laryngological  findings,  states 
that  when  a  laryngeal  catarrh  begins  to  localize  itself  and  becomes 
unilateral,  it  is  suspicious.  Next  to  this,  he  considers  highly  signifi- 
cant a  grayish  wrinkling  of  the  posterior  commissure  and  a  table-like 
elevation  of  its  mucous  membrane.  Early  changes  are  also  found 
in  the  processus  vocalis,  the  posterior  insertion  of  one  cord,  or  the  body 
of  the  cord  itself. 

Ulcers  of  the  cord,  instead  of  being  localized  in  one  spot  may  be 
scattered  along  the  edge,  producing  the  characteristic  nibbled-out 
appearance,  but  in  most  cases  the  posterior  end  of  the  cord  is  red, 
beefy  and  thickened.  Thickening  and  yellowing  of  the  false  cords 
or  ventricular  bands  are  other  early  changes  mentioned  by  Minor, 

1  Ztschr.  f.  Tuberkulose,  1910,  xvi,  338. 

2  Berl.  klin.  Wochenschr.,  1914,  li,  1419. 

3  National  Assn.  Study  and  Prev.  Tuberp.,  1910,  vi,  1.S6. 


LARYNGEAL   TUBERCULOSIS 


411 


and  also  localized  congestions  or  anteroposterior  thickenings  of  the 
arytenoids. 

Thickening  and  even  ulceration  of  the  posterior  wall  of  the  larynx 
is  another  early  sign.  Uniform  redness  of  both  vocal  cords  is  not 
pathognomonic  of  tuberculosis,  but  when  one  cord  is  red  while  the 
other  remains  normal  or  is  pale,  tuberculosis  is  probably  present. 

With  the  advance  of  the  process  the  smooth  and  shiny  appearance 
of  the  parts  is  changed  owing  to  the  ulceration.  The  infiltration  often 
affects  the  epiglottis,  producing  that  pale,  rounded,  sausage-like  body 


Fig.  78. — A  tubercular  ulcer  on  the  left  ventricular  band  and  left  vocal  cord.  Pear- 
shaped  edematous  swelling  of  aryepiglottic  folds,  more  intense  on  the  side  of  the  ulcera- 
tion.     (Cohen.) 

which  may  attain  such  dimensions  as  to  obstruct  the  view  of  the  inte- 
rior of  the  larynx.  The  arytenoid  cartilages  often  change  into  pyriform 
bodies.  When  the  infiltration  begins  to  ulcerate,  the  characteristic 
worm-eaten  appearance  of  the  parts  is  seen,  together  with  caries, 
perichrondritis,  necrosis,  and  exfoliation  of  parts  of  the  cartilages. 

In  cases  in  which  the  infiltration  begins  in  one  or  both  vocal  cords 
or  the  ventricular  bands,  or  the  interarytenoid  region,  the  prognosis 


Fig.  79. — Tubercular  infiltration  of  the  interarytenoid  space  with  tubercular  papil- 
lomata  of  both  vocal  cords.  Characteristic  edematous  infiltration  of  the  aryepiglottic 
folds.     (Cohen.) 


is  more  favorable.  However,  one  or  both  cords  may  be  destroyed  by 
ulceration.  In  far  advanced  cases  all  parts  may  be  destroyed,  includ- 
ing the  epiglottis,  of  which  only  a  short  stump  may  be  left. 

Prognosis. — The  outlook  in  phthisis  complicated  by  tuberculous 
laryngitis  is  rather  gloomy,  though  not  invariably  fatal,  as  was  once 
thought.  Thirty-five  years  ago  Morell  Mackenzie  stated  that  "it  is 
not  certain  that  any  cases  ever  recover."  His  statistics  showed  that 
it  reduced  the  average  expectation  of  life  to  twelve  or  eighteen  months, 
very  few  patients  living  more  than  two  and  a  half  years.     But  since 


412  COMPLICATIONS  OF  PHTHISIS 

phthisis  has  decreased  in  mahgnancy  during  recent  years,  patients 
suffering  from  laryngeal  tuberculosis  have  also  benefited  and  we  now 
know  that  many  recover.  The  lesion  in  the  throat  may  heal,  as  has 
been  found  by  careful  studies  of  postmortem  findings. 

The  laryngeal  lesion  per  se  only  rarely  kills  the  patient  and  it  has 
been  stated  that  consumptives  never  die  from  the  larynx.  This  is 
wrong,  of  course,  because  we  occasionally  see  a  case  of  sudden  death 
from  asphyxia,  or  edema  of  the  glottis.  The  bulk  of  the  patients  with 
laryngeal  complication  die  as  a  result  of  the  severity  of  the  pulmonary 
lesion,  or  inanition  due  to  painful  deglutition.  In  fact,  when  the 
larynx  is  extensively  involved,  producing  dysphagia,  dysphonia,  etc., 
a  fatal  issue  may  be  expected  sooner  or  later.  If  the  lesions  in  the  lung 
and  larynx  are  not  sufficient  to  kill  the  patient  he  will  die  as  a  result 
of  inanition. 

The  milder  forms  of  laryngeal  tuberculosis  have  a  better  outlook. 
Many  heal  spontaneously  without  any  local  treatment.  The  general 
treatment  instituted  often  hastens  recovery  from  the  laryngeal  lesion. 
Very  often  the  condition  of  the  larynx  goes  hand-in-hand  with  the 
general  condition  of  the  patient,  both  improving,  or  aggravating 
simultaneously.    Others  are  benefited  by  local  treatment. 

Tuberculous  Ulceration  of  the  Intestines. — The  frequency  of  intes- 
tinal ulcerations  found  at  autopsies  on  tuberculous  subjects  would 
indicate  that  they  are  more  frequent  than  they  are  diagnosed  intra 
vitem.  Thus  Louis  found  ulcers  in  five-sixths  of  his  cases;  Bayle 
and  Lebert  in  two-thirds;  Williams  found  at  the  Brompton  Hospital 
postmortems  in  81  per  cent,  intestinal  ulcerations  of  a  tuberculous 
nature;  and  Percy  Kidd  found  them  in  71  per  cent.  While  they  are 
responsible  for  the  diarrhea  in  advanced  phthisis  in  most  cases,  in 
many  it  is  due  to  the  toxemia,  the  toxic  substances  in  the  blood  being 
eliminated  through  the  intestines,  or  swallowed  sputum  is  the  cause. 
Lardaceous  disease  of  the  intestines  is  very  frequently  responsible, 
while  errors  in  diet,  especially  an  excess  of  fat  or  of  milk,  may  induce 
diarrhea  which  is  difficult  to  control. 

There  may  be  eight,  ten,  or  even  twenty  motions  a  day,  expelling 
loose,  dark  or  chocolate-colored  matter,  exceedingly  fetid,  and  it  may 
contain  small  sloughs  from  the  bowels.  Quite  often  it  is  tinged  with 
blood,  but  copious  hemorrhages  from  the  bowel  are  exceedingly  rare. 
John  M.  Cruice^  says  that  when  they  do  occur  it  is  of  grave  prognostic 
significance.  The  first  case  of  this  kind  was  reported  by  Tonnelle  in 
1829.  In  1892  Guyenet  could  find  only  15  cases  in  medical  literature 
and  Cruice  found  10  additional  cases  in  1913.  Although  the  prog^ 
nosis  is  very  grave  in  intestinal  hemorrhage,  Peters,  Bullock  and 
Bonney  report  cases  that  recovered. 

One  characteristic  of  tuberculous  diarrhea  is  its  persistence.  It 
may  be  checked  by  proper  dietetic  and  medicinal  treatment,  but  no 

»  Medical  Record,  1913,  Ixxxiv,  471. 


PERITONITIS  413 

sooner  is  this  omitted  than  it  reappears.  With  the  diarrhea  the 
emaciation  proceeds  at  a  rapid  pace  and  they  usually  foreshadow 
quick  relief  from  the  suffering.  I  have  seen  patients  who  have  been 
gaining,  lose  within  one  week  all  they  have  gained  in  months,  and 
within  two  to  four  weeks  they  were  reduced  to  mere  skeletons. 

Diagnosis. — It  is  very  difficult  to  say  with  certainty  whether  a  diar- 
rhea in  a  consumptive  is  due  to  toxemia  or  to  intestinal  ulceration. 
Tenderness  is  often  found  in  the  right  illiac  fossa,  but  it  may  be  all 
over  the  abdomen  or  any  part  of  it.  J.  Walsh^  made  a  thorough 
study  of  the  symptomatology  of  intestinal  ulceration,  comparing 
it  with  autopsy  findings  in  100  cases  at  the  Phipps  Institute.  The 
usual  symptoms  relied  on — diarrhea,  and  abdominal  pains,  tender- 
ness and  rigidity,  especially  in  the  region  of  the  ileocecal  valve — were 
carefully  studied.  He  found  that  singly  these  symptoms  add  little 
or  nothing  to  the  diagnosis  of  intestinal  tuberculosis,  nor  do  any  two, 
or  all  four  when  found  in  the  same  patient,  because  they  may  be 
encountered  while  the  autopsy  shows  no  ulcerations  in  the  intestines 
and  the  reverse.  The  presence  of  an  ischiorectal  abscess  in  an  advanced 
case  adds  to  the  probabilities  of  intestinal  ulcerations.  Nor  has  he 
found  any  relation  between  the  presence  or  absence  of  albumin  in  the 
urine,  or  the  results  of  the  diazo-reaction,  or  indican  in  the  urine,  and 
intestinal  ulceration.  He  concludes  that  the  diagnosis  of  intestinal 
tuberculosis  cannot  be  made  with  the  slightest  degree  of  certainty 
from  our  present  known  symptoms,  and  since  the  condition  carries 
with  it  such  an  unfavorable  prognosis,  he  advises  that  it  is  best  that 
the  diagnosis  should  not  be  made,  so  that  the  patient  will  have  a  better 
chance  for  hopeful  treatment. 

While  the  outlook  for  healing  of  these  ulcers  is  remote,  yet  it  is 
possible.  Amenomiya^  shows  that  regeneration  and  healing  are  possible, 
even  without  scar  formation,  but  the  muscular  coat  is  never  regen- 
erated. 

Peritonitis. — The  pathogenicity  of  tuberculous  peritonitis  as  a 
complication  of  phthisis  is  no  more  the  disputed  problem  which  it 
was  formerly.  Considering  the  frequency  of  bacillemia  in  phthisis, 
it  is  clear  that  the  blood  may  bring  tubercle  bacilli  to  the  peritoneum 
just  as  readily  as  to  other  serous  membranes.  It  is  not  as  frequent  a 
complication  as  is  laryngeal  or  intestinal  tuberculosis,  but  it  appar- 
ently occurs  more  often  than  is  suspected  at  the  bedside,  and  we  are 
at  times  surprised  to  find  it  at  the  autopsy  when  intra  vitem,  even  in 
carefully  watched  cases,  it  was  not  suspected. 

Authors  disagree  as  to  its  frequency  in  phthisis.  Miinstermann* 
found  it  in  5  per  cent,  of  cases;  Borschke^  in  16.17  per  cent.  In  his 
autopsy  material  P.  Horton-Smith  Hartley  found  it  in  only  3.4  per 

1  National  Assn.  Study  and  Prev.  Tuberc,  1909,  v,  217. 

2  Virchows  Archiv,  1910,  cci,  231. 

3  Die  Bauchfelltuberkulose,  Munich,  1890. 
^  Virchows  Archiv,  1892,  cxxvii,  121. 


414  COMPLICATIONS  OF  PHTHISIS 

cent,  of  cases.  Perforation  of  tuberculous  ulcers  of  the  bowels  were 
observed  in  3  cases  out  of  263  autopsies,  or  a  percentage  of  1.1,  the 
perforation  in  each  of  the  instances  occurring  in  the  ileum.  It  appears 
to  be  very  frequent  in  acute  miliary  tuberculosis,  but  in  chronic  pul- 
monary tuberculosis  it  is  less  often  encountered.  While  in  many  cases 
the  infection  of  the  peritoneum  can  only  be  explained  by  assuming 
that  the  bacilli  were  brought  there  by  the  blood,  in  a  considerable 
number  they  may  travel  by  way  of  the  lymphatics  from  the  pleura, 
the  pericardium,  from  the  mesenteric  lymph  glands  and  above  all  by 
contiguity  from  infiltrated  Peyer's  patches  and  ulcers  of  the  intes- 
tines. They  may  also  come  by  continguity  from  tuberculous  lesions 
of  the  urogenital  system,  especially  from  the  adrenals  which  are  often 
the  seat  of  tuberculous  changes  in  phthisis. 

Symptoms. — We  meet  mainly  with  two  forms  of  this  complication: 
dry,  adhesive,  and  moist  or  exudative,  both  of  which  may  be  acute  or 
chronic.  During  the  course  of  phthisis  the  acute  form,  in  the  clinical 
sense,  is  usually  due  to  perforation  of  an  intestinal  ulcer,  or  more  rarely 
a  pyothorax  breaking  into  the  peritoneal  cavity,  when  it  may  produce 
suppurative  peritonitis.  In  one  case  in  which  during  life  the  condition 
was  not  even  suspected,  I  found  at  the  autopsy  a  minute  opening 
through  the  diaphragm  permitting  leakage  of  the  pus  from  a  pyo- 
pneumothorax. Fenwick^  maintains  that  in  some  cases  there  may  be 
premonitory  symptoms,  viz.,  pain  for  a  few  days  before  actual  per- 
foration takes  place  from  a  tuberculous  intestinal  ulcer;  in  others 
there  may  be  bilious  vomiting,  the  abdomen  is  distended,  and  hyper- 
resonant  on  percussion.  These  premonitory  symptoms  are  obviously 
due  to  local  acute  peritonitis.  The  actual  perforation  may  occur  dur- 
ing straining  at  stool,  during  an  attack  of  vomiting  or  retching,  or 
altogether  while  the  patient  is  at  rest.  Some  patients  feel  an  acute 
pain  or  a  sensation  as  if  something  had  given  way  in  the  abdomen. 
Collapse  ensues  and  within  a  few  hours  or  days  the  patient  succumbs 
to  cardiac  failure.  Some  recuperate  from  the  shock  but  they  suc- 
cumb w^ithin  a  few  days  to  the  symptoms  of  acute  peritonitis,  or  more 
rarely  to  exhaustion. 

The  chronic  form  may  be  overlooked  because  it  often  runs  its  course 
symptomless.  The  patient  may  complain  of  abdominal  pain,  vomit 
and  have  diarrhea,  but  these  symptoms  are  very  frequent  during  the 
course  of  phthisis  without  any  peritoneal  complication.  On  the  other 
hand,  there  are  cases  with  peritonitis  in  which  all  these  symptoms  are 
lacking.  The  ascitic  form  is  exceedingly  rare  in  phthisis,  though  now 
and  then  we  meet  with  a  case  in  which  the  abdomen  is  filled  with 
fluid.  To  be  sure  there  are  many  cases  with  exudates,  but  they  usually 
escape  detection  until  they  assume  large  dimensions — 1500  c.c.  of 
fluid  in  the  peritoneal  cavity  may  be  in  the  pelvis,  etc.,  and  not  be 
discovered  by  ordinary  examination. 

1  The  Dyspepsia  of  Phthisis,  London,  1894,  p.  176. 


PERITONITIS  415 

The  adhesive  form  is  characterized  by  the  formation  of  adhesions 
and  cicatricial  contractions  of  the  mesentery  and  gluing  together 
loops  of  the  gut  are  very  frequent.  Especially  frequent  are  adhesions 
of  the  peritoneum  to  the  liver  and  spleen.  The  adhesions  and  cicatri- 
cial contractions  at  times  produce  incomplete  stenosis  of  the  intestine 
with  resultant  persistent  constipation  and  uncontrollable  vomiting. 
Colicky  pains  increased  by  pressure  and  on  movement  may  be 
observed.  In  these  cases  the  emaciation  may  be  extreme  despite 
the  fact  that  the  local  lesion  in  the  lungs  is  not  extensive,  nor  very 
active.  When  the  inflammation  in  the  peritoneum  is  limited  and 
circumscribed,  which  is  not  infrequent,  the  pain  may  be  localized 
at  one  point.  It  is  noteworthy  that  fever  may  be  absent,  but  in  most 
cases  of  active  phthisis,  pyrexia  due  to  the  lung  lesion  is  so  frequent 
that  it  cannot  be  utilized  for  diagnostic  purposes  as  to  the  presence 
or  absence  of  a  peritoneal  complication.  On  the  other  hand,  when  the 
lesion  in  the  lung  is  quiescent  or  latent,  the  complicating  peritonitis 
may  pass  an  apyretic  course.  In  many  cases  there  is  diarrhea  due  to 
intestinal  catarrh  or,  more  frequently,  to  ulcerations  of  the  intestine. 

As  was  already  stated,  many  cases  run  their  course  painlessly.  When 
copious,  the  exudate  is  easily  detected  by  the  usual  physical  signs. 
In  others  it  is  encysted  because  of  plastic  fibrinous  formation.  Thor- 
mayer^  described  physical  signs  which  he  considers  characteristic  of 
tuberculous  and  carcinomatous  peritonitis.  He  found  that  tympany 
is  very  frequently  elicited  on  the  right  side  of  the  abdomen,  while  in 
the  left  side  a  dull  note  is  elicited  by  percussion.  He  explains  this 
phenomenon  on  anatomical  grounds:  The  mesentery  on  the  right 
side  usually  contracts  more  than  on  the  left,  and  thus  intestinal  coils 
are  apt  to  be  drawn  to  the  right  by  the  shrinking  mesentery;  tympany 
is  then  elicited  over  these  distended  intestinal  coils.  It  is,  however, 
an  inconstant  symptom  and  if  it  occurs  at  all,  it  is  discerned  late,  after 
the  organization  of  the  exudate. 

At  times  we  may,  on  palpating  the  abdomen,  feel  some  crepitation, 
and  in  some  cases  I  have  even  heard  friction  sounds  while  auscultating 
with  the  stethoscope.  On  rare  occasions,  tumor-like  masses  are 
palpable  in  the  abdomen.  When  localized  in  the  right  side  they  may 
simulate  appendicitis.  In  one  case  under  my  care  repeated  attacks  of 
pain  in  the  right  lower  part  of  the  abdomen,  constipation,  and  even 
rigidity  of  the  rectus  muscle  exquisitely  simulated  appendicitis.  But 
later  when  a  tumor  was  palpable  the  condition  was  cleared  up.  In 
another  case  under  my  care  symptoms  not  unlike  those  of  intestinal 
obstruction  were  present  in  a  woman  with  tuberculous  pleurisy,  and 
the  advisability  of  operative  interference  was  seriously  considered, 
but  the  patient  recovered.  It  appears  that  tuberculous  cicatrices 
causing  narrowing  of  the  gut  may  stretch  and  thus  relief  ensues.  This 
is  also  true  of  cicatrices  of  the  intestinal  wall  caused  by  healing  tuber- 
culous ulcers. 

1  Ztschr.  f.  klin.  Med.,  1884,  vii,  378. 


416  COMPLICATIONS  OF  PHTHISIS 

Tuberculous  Meningitis. — Many  phthisical  patients  show  cerebral 
symptoms  a  few  days  before  death,  but  at  the  autopsy  no  changes 
are  found  within  the  cranium.  But  in  these  cases  the  diagnosis  is  not 
important  because  the  seriousness  of  the  condition  is  evident  from  the 
other  symptoms.  The  problem  of  the  presence  or  absence  of  menin- 
geal implication  in  phthisis  has,  however,  a  great  prognostic  value  in 
cases  showing  a  tendency  to  quiescence  or  cure,  and  the  occurrence 
of  symptoms  suggestive  of  tuberculous  meningitis  is  more  than  dis- 
quieting. 

The  onset  of  this  complication  is  usually  insidious.  For  some  days, 
at  times  for  more  than  two  weeks,  the  patient  complains  of  headache, 
is  irritable  and  fretful  and  vomits  most  of  the  food  and  drink  given  him. 
Tuberculous  patients  only  rarely  suffer  from  headache,  unless  pyrexia, 
or  some  nasal  or  gastro-intestinal  trouble  is  responsible.  If  a  persist- 
ent headache  cannot  be  explained  as  due  to  some  other  cause,  meningitis 
is  to  be  thought  of.  If  there  is  also  vomiting  the  diagnosis  is  greatly 
supported,  though  not  conclusive.  There  are  also  noted  early  con- 
fusion of  ideas,  impaired  memory,  photophobia,  defective  vision, 
drowsiness  and  somnolence  which  may  pass  into  coma,  or  convulsions. 

The  pulse  is  rather  slow  in  most  cases,  though  at  times  we  meet 
with  a  case  in  which  it  is  accelerated.  But  it  is  very  frequently  irreg- 
ular. The  temperature  may  be  high,  though  this  is  rare.  In  most 
cases  it  does  not  exceed  102°  F.  Constipation  is  a  frequent  symptom, 
and  during  the  last  days  retention  of  urine  may  occur.  But  these 
are  not  constant  symptoms.  Patients  with  diarrhea  may  continue  with 
loose  stools  and  in  the  later  stages  involuntary  evacuation  of  urine 
and  stools  may  occur. 

In  most  of  my  cases  many  of  these  symptoms  were  noted  early  but 
they  were  not  continuous;  occurring  one  day  and  disappearing  the 
next,  to  reappear  again.  This  intermittency  is  a  very  important  point 
in  the  diagnosis  of  obscure  cases.  Very  early  there  is  often  noted  a 
complete  change  in  the  character  of  the  individual.  The  hopefulness 
and  euphoria  disappear:  the  patient  becomes  disinterested  in  things 
which  were  vital  to  him  before.  This  passes  into  drowsiness  and  he 
refuses  to  answer  questions,  though  when  waked  up  he  recognizes 
the  person  addressing  him.  Some  act  as  if  they  were  under  the  influ- 
ence of  alcohol,  and  in  one  case  we  suspected  that  the  patient  had 
imbibed  whisky  and  rebuked  him  for  violating  the  hospital  rules. 
Occasionally  hysteria  will  simulate  meningitis  exquisitely.  Kernig's 
sign  is  present  in  most  cases,  though  in  some  it  is  lacking  at  the  early 
stage.  At  the  end  Cheyne-Stoke's  breathing,  paralysis  of  some  cranial 
nerves,  optic  neuritis  and  convulsions  may  occur. 

In  most  of  the  cases  under  my  care  lumbar  puncture  has  not  been  of 
material  assistance  for  early  diagnosis.  Very  often  the  fluid  is  cloudy, 
shows  an  excess  of  lymphocytes  and  is  rarely  sanguineous.  But  it 
must  be  mentioned  that  an  excessive  number  of  lymphocytes  is  not 
always  a  sure  sign  of  tuberculous  meningitis.    In  a  large  proportion 


CARDIAC  COMPLICATIONS  417 

of  cases  the  cerebrospinal  fluid  shows  no  change  in  its  cytology,  though 
the  course  of  the  disease  and  the  autopsy  leave  no  doubt  that  there 
was  meningitis.  In  some,  though  not  in  all,  tubercle  bacilli  may  be 
discovered  in  the  cerebrospinal  fluid.  Usually  the  fluid  is  under  high 
pressure,  but  I  have  seen  cases  in  which  it  squirted  out  forcibly,  yet 
the  subsequent  course  showed  that  there  was  no  meningitis. 

Patients  with  this  complication  do  not  last  over  two  weeks,  as  a  rule, 
though  I  have  seen  some  who  have  lasted  more  than  a  month.  A  fatal 
prognosis  should  be  given  whenever  meningitis  is  diagnosed;  the  few 
cases  of  recovery  which  have  been  reported  may  be  considered  medical 
curiosities. 

Cardiac  Complications. — We  have  shown  that  phthisis  only  except- 
ionally develops  in  persons  suffering  from  chronic  endocarditis,  except- 
ing in  those  with  congenital  heart  disease  (p.  91).  But  endocarditis 
may  develop  during  the  course  of  phthisis,  either  due  to  complicating 
rheumatic  disease,  or  any  other  accidental  septic  process,  as  tonsil- 
litis, etc.  The  verrucose  excrescences  on  the  cardiac  valves  often 
found  at  autopsies  on  phthisical  subjects  are  usually  caused  by  other 
microorganisms,  though  Heller,  Leyden,  Benda,  Tripier,  and  others 
maintain  that  tubercle  bacilli  may  be  responsible  in  some  cases. 

Myocarditis.— In  most  cases  heart  failure  in  advanced  phthisis  is 
due  to  myocarditis,  with  dilatation  of  the  right  heart;  to  tuberculous 
pericarditis,  and  also  to  dilatation  with  cardiac  displacement.  Like 
in  other  chronic,  cachectic,  and  exhausting  diseases,  the  myocardium 
partakes  in  the  atrophy  of  the  muscular  system,  and  gives  way  from 
sheer  exhaustion.  In  fibroid  phthisis,  and  the  pleural  forms  of  chronic 
phthisis,  the  induration  in  the  lungs  interferes  with  the  circulation, 
and  heart  failure  of  variable  degree  is  the  result.  Before  the  onset  of 
decompensation,  hypertrophy  of  the  right  ventricle  is  quite  common, 
especially  in  fibroid  phthisis. 

Pulsations  in  the  epigastrium  and  accentuation  of  the  second  pul- 
monic sound  reveal  this  condition.  However,  accentuation  of  the 
second  pulmonic  sound  may  be  present  without  hypertrophy  when 
the  left  lung  is  retracted  through  infiltration  or  shrinkage  and  reveals 
the  left  heart.  The  constitutional  symptoms  of  heart  failure — dyspnea, 
edema,  etc. — may  be  quite  marked. 

Pericarditis.— Pericarditis  may  occur  during  the  course  of  chronic 
phthisis.  Several  cases  of  primary -tuberculous  pericarditis  have  been 
reported.  In  chronic  phthisis  the  pericardial  sack  may  be  implicated 
by  tuberculous  processes  of  the  pleura  or  mediastinal  glands.  Adhe- 
sions between  the  pleura  and  pericardium  are  often  found  and  with 
the  shrinkage  of  the  affected  lung,  the  heart  is  pulled  out  of  its  normal 
position,  as  has  already  been  described  (pp.  335  and  344). 

Very  often  we  meet  with  acute  pericarditis  in  phthisis  and  pleuro- 
pericardial  friction  sounds  may  be  audible.  The  symptoms  and  signs 
of  adhesive  pericarditis  are  not  rare  in  chronic  phthisis — systolic  re- 
traction of  the  chest  wall  at  the  apex,  engorgement  of  the  yeins  in  the 
27 


418  COMPLICATIONS  OF  PHTHISIS 

neck,  disappearance  of  weakening  of  the  pulse  during  inspiration — 
pulsus  paradoxus,  etc. 

On  very  rare  occasions  we  meet  with  acute  pericarditis  coming  on 
suddenly  with  pain  in  the  cardiac  region,  dyspnea,  cyanosis,  cardiac 
irregularity,  etc.  In  one  case  under  my  care  the  symptoms  simulated 
pneumothorax.  Careful  examination  of  the  heart,  however,  clears  up 
the  case.  The  cardiac  dulness  is  increased,  friction  sounds  are  audible, 
the  apex  beat  disappears  with  the  effusion.  The  pericardium  may 
also  be  implicated  in  cases  of  pneumothorax,  producing  pneumoperi- 
carditis,  as  has  already  been  mentioned. 

Phlebitis  and  Thrombosis. — Although  occurring  quite  frequently 
during  the  course  of  phthisis,  phlebitis  and  thrombophlebitis  are  only 
rarely  mentioned  as  complications  of  this  disease.  Older  clinicians, 
as  Hoffmann  in  1740,  and  after  him  Hunter,  Louis,  Trousseau,  and 
others  have  mentioned  it,  and  Cursham  wrote  in  1860  on  ''Causes 
of  Obstruction  of  the  Veins  of  the  Lower  Extremities  Causing  Edema 
of  the  Corresponding  Limb  and  Occurring  in  Phthisical  Patients." 
Most  writers  are  inclined  to  attribute  them  to  the  tuberculous  toxemia, 
while  others  have  found  in  them  an  instance  of  marantic  thrombosis. 
But  recently  Gustav  Liebermeister,^  in  a  thorough  clinical  and  patho- 
logical study  of  the  subject,  attributes  them  to  the  direct  action  of  the 
bacilli  on  the  bloodvessels,  finding  as  he  does  that  nearly  all  tubercu- 
lous patients  have  a  bacteremia.  Haushalter  and  Etienne,  Vaquez, 
Sabrazes  and  ]Mongour,  Chantemesse  and  Widal,  Lesne  and  Revaut, 
Liebermeister,  and  others  have  found  virulent  tubercle  bacilli  in  such 
thrombi. 

Phlebitis  and  thrombosis  in  phthisis  usually  occur  in  the  femoral 
vein,  though  at  times  we  meet  with  cases  in  which  the  vena  cava,  the 
innominate,  jugular,  subclavian,  or  renal  veins  are  affected  or  even 
the  cerebral  sinuses.  The  frequency  of  this  complication  is  given  by 
P.  R.  DowdelP  as  30  among  1300  consumptives,  or  1.5  per  cent.  H. 
Ruge  and  Hierokles^  found  it  nineteen  times  among  1778  cases  of 
pulmonary  tuberculosis,  or  1  per  cent.  In  my  experience  it  appears 
to  be  even  more  frequent  in  advanced  and  active  cases  of  phthisis. 
P.  Horton-Smith  Hartley  found  thrombosis  of  veins  in  2.6  per  cent, 
of  263  cases  which  came  to  autopsy.  In  males  the  percentage  was 
but  1,  while  in  females  it  was  6.6. 

Phlebitis  is  very  often  found  in  the  veins  of  the  upper  or  lower 
extremities,  especially  in  very  active  cases  running  high  fever.  ]Mostly 
the  medium-sized  or  small  veins  are  affected.  Clinically,  the  thicken- 
ing of  the  veins  of  the  upper  extremities  are  more  easily  recognized  by 
palpation  because  of  the  lesser  thickness  of  the  muscles  and  adipose 
tissue.  The  affected  veins  are  tender  to  the  touch  and  also  painful  on 
motion  of  the  limb.    Edema  of  the  extremities  is  exceptional  in  simple 

1  Virchows  Archiv,  1909,  cxcviii,  332. 

2  Amer.  Jour.  Med.  Sci.,  1893,  cv,  641. 
3Berl.  klin.  Wochcnschr.,  1899,  xxxvi,  73. 


PHLEBITIS  AND  THROMBOSIS  '  419 

phlebitis,  though  in  some  cases  it  may  occur.  The  phlebitis  may 
disappear,  to  reappear  again  and  in  most  cases  it  is  persistent  till 
thrombosis  also  occurs,  or  till  the  fatal  issue  of  the  case.  In  fact, 
phlebitis  is  an  ominous  complication.  A  thrombus  may  develop  and 
it  may  soften  and  be  carried  by  the  circulating  blood  to  distant  organs 
producing  pulmonary  embolism  or  infarction.  It  may  organize  and 
remain  as  a  firm,  thick  cord.  Hirtz^  described  cases  of  phlebitis  and 
thrombosis  occurring  during  the  incipient  stage  of  phthisis,  or  even 
preceding  the  actual  onset  of  the  disease,  especially  in  chlorotic  girls. 

Thrombosis  of  the  Femoral  Veins. — Thrombosis  occurs  most  frequently 
in  the  femoral  vein  but,  as  was  pointed  out  by  Dowdell,  usually  the 
popliteal  vein  is  found  to  contain  a  clot  of  older  date,  while  in  some 
the  saphena  vein  is  plugged  and  rarely  the  superficial  veins  of  the  leg 
and  thigh,  as  well  as  the  main  trunk  from  the  tibial  vein  upward  is 
thrombosed.  Dowdell,  Ruge  and  Hierokles,  Liebermeister,  and 
others  have  also  found  thrombosis  of  the  uterine  and  brachial  veins, 
the  prostatic  plexus,  and  embolism  of  distant  arteries  is  said  to  be  not 
uncommon.  As  is  the  case  with  phlebitis,  thrombosis  is  found  mostly 
in  far-advanced  but  acutely  running  cases  and  is  usually  the  precursor 
of  a  fatal  issue. 

The  most  important  symptom  is  edema  of  the  affected  limb.  The 
onset  is  usually  slow  and  insidious,  the  swelling  coming  on  gradually. 
Pain  is  often  felt  for  a  few  days  after  the  onset  of  edema,  but  in  many 
cases  this  is  lacking.  When  present  it  is  mainly  felt  in  the  popliteal 
space  where  tenderness  may  be  elicited.  Inasmuch  as  practically  all 
these  patients  have  symptoms  of  active  phthisis,  the  temperature 
is  not  an  aid  in  the  diagnosis — it  is  continuous  or  hectic,  as  the  case 
may  be;  the  onset  of  the  thrombosis,  edema,  etc.,  has  hardly  any  in- 
fluence on  the  pyrexia.  In  some  cases  under  my  care  there  were 
disturbances  in  sensation  of  the  affected  limb,  which  was  cold,  numb, 
or  tender.  In  one  case  the  pain  was  excruciating  and  morphin  alone 
was  effective  in  relieving  it  in  part.  When  the  deeper  veins  of  the 
muscles  are  plugged,  which  is  not  rare,  there  may  be  severe  pain  and 
hyperesthesia  of  the  calf  of  the  affected  leg.  Diagnosis  may  be  difficult 
at  first,  but  as  soon  as  the  edema  appears,  the  cause  is  clear.  In  some 
cases  the  thrombus  in  the  affected  vein  is  so  thick  as  to  be  palpable. 
I  have  many  times  been  able  to  palpate  the  femoral  and  crural  veins 
as  thick,  firm  cords  tender  to  the  touch. 

Diagnosis. — In  most  cases  the  diagnosis  of  thrombosis  and  phlebitis 
is  rather  easy.  It  is  to  be  differentiated  from  edema  of  the  extremities 
common  in  phthisis  and  due  to  cardiac  and  renal  insufficiency,  and 
from  cachectic  edema  which  is  frequently  seen  in  the  terminal  stages 
of  this  disease.  Thrombosis  always  begins  in  one  extremity  and  is 
confined  to  it,  or  marked  on  one  side  when  fully  developed.  It  is 
tender  to  the  touch  along  the  course  of  the  veins  and  not  necessarily 

1  Sen).  Med.,  1S94,  xiv,  274. 


420  COMPLICATIONS  OF  PHTHISIS 

over  the  edematous  skin.  The  dilated  superficial  veins  may  at  times 
contain  clots.  On  the  other  hand,  edema  due  to  cardiac  or  renal 
disease  is  accompanied  by  signs  and  symptoms  of  these  conditions,  both 
lower  extremities  are  affected  by  the  swelling,  and  the  tenderness  along 
the  course  of  the  veins  is  lacking.  Cachectic  edema  occurs  on  both 
sides,  is  painless  and  subsides  when  the  patient  is  kept  in  the  recum- 
bent position  for  some  time.  At  times  intra-abdominal  pressure  on  the 
common  or  external  iliac  vein,  or  on  the  femoral  may  produce  edema 
of  one  extremity  not  unlike  that  of  thrombosis.  The  same  condition 
may  occur,  though  very  rarely,  in  the  upper  extremity  when  intratho- 
racic pressure  is  exerted  by  enlarged  glands  in  the  thorax  on  the  main 
trunks  of  the  veins.  But  careful  examination  will  usually  reveal  the 
tumor  or  the  glands  which  are  responsible. 

Thrombosis  of  the  Jugular  Vein.- — ^Thrombosis  causing  edema  of  the 
upper  extremity  is  very  rare,  but  it  does  occur.  Two  cases  have  come 
under  my  observation.  Humphrey^  reported  such  a  case  in  1859; 
Lesague^  observed  in  1870  a  case  of  phthisis  complicated  by  the  for- 
mation of  a  thrombus  in  the  external  jugular,  subclavian,  and  humeral 
veins.  Ten  days  after  the  appearance  of  the  thrombus  it  was  com- 
pletely softened  and  all  symptoms  of  plebitis  disappeared.  But 
in  all  other  cases  reported,  death  supervened  within  a  couple  of  weeks 
after  the  establishment  of  thrombosis.  The  symptoms  are  edema, 
pain,  etc.,  of  the  upper  extremity.  In  1904  Charles  J.  Aldrich^  collected 
from  the  literature  9  cases  of  this  complication  of  phthisis  and  reported 
one  of  thrombosis  of  the  left  internal  jugular  with  extension  through  the 
subclavian  down  the  axillary  into  the  basilic  veins.  Two  weeks  later 
a  like  thrombus  appeared  in  the  right  side  and  extended  to  the  veins 
of  the  arm.  Death  was  due  to  cerebral  sinus  thrombosis  from  exten- 
sion of  the  thrombus  in  the  right  internal  jugular  vein.  In  one  of  my 
cases  thrombosis  of  the  right  internal  jugular  vein  occurred  in  a 
patient  with  a  spontaneous  pneumothorax. 

Prognosis  of  Thrombosis. — The  prognosis  is  fatal  in  nearly  all  cases 
because  of  the  severity  of  the  tuberculous  process,  occurring  as  it  does 
mainly  in  rapidly  advancing  cases  of  phthisis.  Death  may  be  due  to 
secondary  emboli  which  cause  sudden  death.  Excepting  Lesague's 
case  mentioned  above,  I  have  not  heard  of  a  patient  with  phthisis 
complicated  by  thrombosis  of  the  upper  or  lower  extremity  surviving 
two  months;    they  usually  succumb  within  one  month. 

Urogenital  Tract. — Of  other  complications  occurring  more  or 
less  often  during  the  course  of  phthisis  may  be  mentioned  tuber- 
culosis of  the  urogenital  tract.  We  have  already  mentioned  that 
albuminuria  is  not  uncommon  in  phthisis.  In  far  advanced  cases, 
nephritis  is  quite  frequent  and  we  may  have  most  of  the  symptoms 
of  this  disease,  especially  edema,  anasarca,  etc.,  and  even  uremia,  which 

'  Brit.  Med.  Jour.,  1859,  582,  601,  619,  G50. 

2  Gaz.  Med.  de  Paris,  1879,  i,  649. 

3  New  York  Med.  Jour.,  1904,  Ixxix,  442. 


PURPURA  421 

is  at  times  difficult  to  differentiate  from  tuberculous  meningitis.  In 
many  of  advanced  cases  we  may  also  note  symptoms  due  to  amyloid 
disease  of  the  kidneys :  Abundance  of  secretion  of  urine  of  low  specific 
gravity  containing  hyaline  casts  and  albumin  in  large  quantities.  But 
in  this  form  of  nephritis  dropsy  is  infrequent.  I  have  been  struck 
with  the  fact  that  in  most  cases  in  which  there  is  considerable  albumin 
in  the  urine  and  dropsy,  the  temperature  drops  down  to  near  normal 
and  very  often  the  activity  of  the  process  in  the  lung  diminishes. 
The  prognosis  is,  however,  not  improved. 

In  some  cases  tuberculosis  of  the  kidneys  supervenes  and  also  of  the 
bladder,  seminal  vesicles,  vas  deferens  and  epididymis.  Tuberculosis 
of  the  kidneys  is  very  difficult  of  diagnosis  in  its  early  stages.  Finding 
acid-fast  bacilli  in  the  sediment  of  the  urine  is  not  sufficient  to  base  a 
diagnosis  in  my  experience,  excepting  when  the  specimen  h'as  been 
obtained  by  catheterization  of  the  ureter.  But  I  h^ve  seen  cases 
in  which  tubercle  bacilli  were  thus  found  yet  the  patient  improved 
without  operation.  Patients  with  tuberculous  pyelitis  suffer  usually 
from  lumbar  pain  of  a  dull  character,  have  pus,  albumin  and  blood, 
renal  epithelium,  and  even  caseous  debris  in  the  urine.  I  have  seen 
cases  in  which  the  pain  occurred  in  paroxysms  and  it  was  difficult  to 
differentiate  from  that  of  renal  colic  due  to  stone. 

Tuberculous  Ulcerations  of  Mucous  Membranes.  —  We  have 
already  pointed  out  that  despite  the  fact  that  so  much  of  tuber- 
culous sputum  passes  through  the  mouths  and  lips  of  phthisical 
subjects,  ulcerations  of  these  parts  are  extremely  rare.  Still  now 
and  then  we  meet  with  cases  of  ulceration  of  the  tongue.  These 
ulcers  are  usually  located  on  the  dorsum  of  the  tongue,  but  in  some  also 
at  the  sides,  the  tip,  and  rarely  on  the  frenum.  I  have  seen  some  with 
ulcers  of  the  soft  palate  and  very  rarely  on  the  posterior  wall  of  the 
pharynx.  These  ulcerations  are  to  be  differentiated  from  specific  and 
malignant  ulcerations.  Inasmuch  as  they  occur  usually  in  the  far- 
advanced  stages  of  the  disease,  the  diagnosis  is  clear,  but  when  occur- 
ring in  a  patient  with  a  slight  pulmonary  lesion,  or  in  one  with  the 
emphysematous  type  of  fibroid  phthisis  the  diagnosis  may  be  difficult, 
though  the  examination  of  a  specimen  from  the  ulcer  for  tubercle 
bacilli  usually  decides. 

Purpura. — I  have  seen  several  cases  of  purpura  hemorrhagica  compli- 
cating advanced  phthisis.  Petechia  are  very  frequent  in  many  cases, 
but  true  purpura  hemorrhagica  with  extensive  ecchymoses  scattered 
over  the  limbs  may  occur,  and  there  may  be  simultaneously  hemor- 
rhages from  some  of  the  mucous  membranes — true  purpura  hemor- 
rhagica. In  3  out  of  the  4  cases  seen  by  me  recently  there  was  also 
albuminuria  and  hematuria,  and  the  patients  succumbed  shortly 
after  the  appearance  of  the  purpura,  and  I  am  inclined  to  agree  with 
John  M.  Cruice^  to  the  effect  that  the  occurrence  of  purpura,  espe- 

1  Amer.  Jour.  Med.  Sci.,  1912,  cxliv,  875. 


422  COMPLICATIONS  OF  PHTHISIS 

cially  the  hemorrhagic  form,  in  the  course  of  tuberculosis  is  always  a 
grave  symptom. 

Its  etiological  relation  to  tuberculosis  is  doubtful.  Some  authors 
are  inclined  to  see  in  the  tubercle  bacillus  a  cause  of  the  purpura,  but 
the  fact  that  it  is  so  extremely  rare  in  phthisical  subjects  shows  that 
when  the  two  diseases  occur  in  the  same  subject,  it  is  in  all  probabil- 
ities a  coincidence.  I  believe  that  Cruice's  observation  that  after  an 
attack  of  piu-piu-a  physical  examination  will  reveal  a  more  advanced 
condition  of  the  lesion,  does  not  at  all  prove  that  the  hemorrhages  into 
the  skin  were  directly  of  a  tuberculous  character;  it  by  no  means 
excludes  the  chances  of  their  being  a  coincidence. 

Superficial  Cold  Abscesses  in  the  Chest  Wall. — This  is  a  very  rare 
complication  of  phthisis  and  may  occur  at  any  stage  of  the  disease, 
mostly  in  the  early  or  second  stages  in  cases  running  a  chronic  com"se. 
The  cause  usually  cannot  be  ascertained — they  are  often  found  unex- 
pectedly. On  the  chest  wall,  along  the  line  of  insertion  of  the  dia- 
phragm, particularly  anteriorly  or  in  the  lower  axillary  region  there  is 
noted  a  circumscribed  swelling,  the  size  of  a  pigeon's  or  hen's  egg, 
painless  and  fluctuating.  There  is  usually  no  surrounding  inflamma- 
tory induration,  and  only  later  the  infected  area  becomes  red  and 
somewhat  tender.  When  incised  a  moderate  amount  of  liquid,  curdy 
pus  is  eliminated,  but  healing  is  slow:  In  most  cases  a  fistula  is  left 
which  persists  for  months ;  or  an  ulcer  remains  which  keeps  on  discharg- 
ing pus  for  a  similar  period,  ^'ery  often  the  fistula  or  ulcer  is  located 
over  a  rib,  the  periosteum  of  which  is  implicated.  In  many  cases 
healing  finally  takes  place  leaving  an  ugly  red  scar. 

The  diagnosis  is  at  times  difficult — there  is  a  question  whether  it 
is  not  an  empyema  pointing  on  the  chest  wall,  particularly  when 
there  are  physical  signs  elicited  in  the  same  area.  A  careful  consider- 
ation of  the  history  and  course  of  the  trouble,  however,  clears  up  the 
diagnosis. 


CHAPTER  XXVII. 
PROGNOSIS  IN  PULMONARY  TUBERCULOSIS. 

The  Curability  of  Phthisis. — Laennec,  the  first  physician  to  make  a 
scientific  study  of  the  pathology  of  phthisis,  pronounced  it  an  incurable 
disease,  saying  "the  possibility  of  curing  phthisis  in  the  first  stage  is 
an  illusion."  Pathological  anatomy  taught  him  that  tuberculosis  is 
an  affection  akin  to  cancer  and  absolutely  incurable ;  that  all  tubercu- 
lous lesions  proceed  from  infiltration  to  caseation  and  finally  to  soften- 
ing. It  appears,  however,  that  even  in  those  days  it  was  already  well 
known  that  if  taken  in  time  the  disease  is  curable. 

The  observations  of  physicians  all  through  the  nineteenth  century 
have  clearly  shown  that  phthisis  is  not  invariably  fatal,  despite  the 
fact  that  the  treatment  applied  during  the  first  half  of  the  nineteenth 
century  should  have  killed  most  of  the  curable  cases,  according  to 
our  understanding  of  the  pathology  and  therapy  of  the  disease.  Still, 
Flint  reported  670  cases  observed  during  a  period  of  thirty-four  years 
and  the  proportion  of  cases  cured  or  arrested  was  not  much  below 
that  which  we  attain  at  present.  Thomas  J.  Mays^  compiled  statis- 
tics of  Flint's  670  cases  and  Williams's  1000  cases  observed  for  twenty- 
two  years,  and  compared  the  results  with  Trudeau's  1060  cases  under 
observation  for  seventeen  years.  The  percentages  of  recoveries  and 
survivals  are  about  the  same,  or  rather  in  favor  of  Flint's  and  Williams's 
cases. 

At  present  we  have  sufficient  and  uncontrovertible  proof  that  tuber- 
culosis is  curable  in  all  its  stages.  Experience  while  making  autopsies 
shows,  in  fact,  that  it  is  the  most  curable  of  chronic  diseases,  consider- 
ing the  enormous  number  of  persons  who  show  healed  or  quiescent 
tuberculous  lesions  in  the  lungs  when  examined  after  death.  And  the 
lesions  discovered  are  often  such  as  to  indicate  that  the  process  was 
quite  extensive  at  the  time  of  its  activity. 

Importance  of  Prognosis. — There  is  no  need  of  elaborating  on  the 
importance  of  prognosis  in  the  practice  of  medicine.  It  is  always 
important  and,  in  the  case  of  tuberculosis,  it  is  at  times  even  more 
important  than  diagnosis.  Indeed,  most  patients  come  with  ready- 
made  diagnoses  and  all  they  want  to  know  is  the  ultimate  outlook. 
"Will  he  recover?"  is  one  of  the  first  questions  after  the  patient  and 
his  friends  are  told  that  there  is  a  tuberculous  lesion.  "  If  so,  how  long 
will  it  take  till  he  recovers?"  Moreover,  it  is  important  to  be  ready 
to  answer  whether  the  patient  after  recovery  will  be  able  to  resume 

1  New  York  Med.  Jour.,  1914,  c,  70. 


424  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

his  occupation,  and  whether  there  is  danger  of  relapse.  In  case  of  an 
unfavorable  prognosis  it  is  often  asked  "how  long  will  the  patient 
last?" 

We  cannot  answer  all  or  most  of  these  questions  in  the  average 
case  with  a  high  degree  of  certainty.  As  J.  Mitchel  Bruce^  says :  prog- 
nosis in  tuberculosis  "is  always  a  difficult  and  often  a  disappointing 
proceeding.  With  all  the  facts  of  a  case  in  our  possession  the  conclu- 
sion we  reach  proves  too  frequently  to  be  false.  Indeed,  paradoxical 
as  it  may  appear,  we  fail  in  prognosis  most  often  because  of  the  very 
number,  variety,  and  different  character  of  the  facts  that  we  discover. 
E.ach  of  our  observations  has  its  own  prognostic  value,  and  most  of 
them  have  a  different  value  in  different  instances  and  at  different  times. 
We  meet  with  an  extraordinary,  variable,  and  therefore  uncertain, 
course  of  the  pathological  process  from  month  to  month.  No  disease 
is  so  difficult  to  deal  with  in  this  connection,  and  we  have  to  confess 
that  we  too  often  find  ourselves  changing  our  forecast  in  both  directions 
from  time  to  time." 

The  difficulties  are,  however,  not  insurmountable  in  many  cases, 
and  we  can  estimate  the  prognosis  of  the  average  patient  in  any  stage 
of  the  disease,  with  a  certain  degree  of  exactitude.  But  in  order  to 
do  this,  we  must  take  into  consideration  all  available  facts  which  may 
have  any  bearing  on  the  course  of  the  disease. 

Elements  of  Prognosis  in  Phthisis. — The  notion  that  this  disease  is 
curable  only  in  its  incipient  stage  is  one  of  the  half-truths  which  have 
gained  universal  credence  because  of  tradition.  There  are  so  many 
exceptions  as  to  almost  nullify  this  ancient  dictum.  We  have  already 
shown  that  it  is  fallacious  to  classify  phthisis  into  three  or  four  stages 
and  to  say  without  reservation  that  in  the  first  stage  it  is  curable; 
in  the  second  stage  the  chances  of  recovery  are  considerably  dimin- 
ished while  in  the  third  stage  it  is  incurable.  There  are  "incipient" 
cases  which  have  no  chance,  irrespective  of  the  treatment  applied; 
while  there  are  many  in  the  third  stage  whose  chances  of  survival  and 
even  of  efficiency  are  excellent.  For  this  reason  we  shall  not  discuss 
the  prognosis  of  phthisis  according  to  the  stages  of  the  disease. 

The  elements  of  prognosis  in  phthisis  reside  in  the  following  factors: 
(1)  The  form  of  the  disease;  (2)  in  a  given  form  of  the  disease,  the 
activity  of  the  process  as  revealed  by  the  constitutional  symptoms 
and  physical  signs;  (3)  the  presence  of  complications;  (4)  the  extent 
of  the  lesion  in  the  lungs;  and  (5)  the  economic  condition  of  the 
patient. 

Prognosis  in  the  Various  Forms  of  Pulmonary  Tuberculosis. — We 
have  seen  from  our  study  of  the  symptomatology  of  phthisis  that  the 
form  of  the  disease  has  a  greater  influence  on  the  ultimate  outlook  than 
the  extent  of  the  lesion  or  even  the  activity  of  the  process.  Thus, 
in  the  pulmonary  form  of  miliary  tuberculosis,  the  chances  of  recovery 

1  Lancet,  1913,  i,  591. 


PROGNOSTIC  SIGNIFICANCE  OF  THE  PATIENT'S  HISTORY     425 

are  nil.  The  patient  will  die  irrespective  of  the  treatment  applied. 
In  acute  pneumonic  phthisis  the  prognosis  is  very  unfavorable,  the 
onlj''  hope  we  may  entertain  is  that  the  disease  will  take  a  turn  to  the 
better  and  pursue  the  course  of  chronic  phthisis.  This  happens  on 
rare  occasions,  but  should  not  be  expected  in  the  average  case.  In  fact, 
we  may  say  that  the  prognosis  is  decidedly  bad  in  these  cases.  The 
patient  usually  lasts  as  many  weeks  or  months  as  one  with  chronic 
phthisis  lasts  years. 

On  the  other  hand,  taking  the  other  extreme,  abortive  tuberculosis, 
we  find  that  the  prognosis  is  favorable  under  all  circumstances.  Prac- 
tically all  patients  recover;  the  vast  majority  without  even  knowing 
that  they  have  been  tuberculous;  or  when  the  disease  has  been  diag- 
nosticated there  often  remains  a  lurking  suspicion  that  it  was  a  false 
alarm,  even  if  tubercle  bacilli  were  discovered  in  the  sputum. 

In  fibroid  phthisis  the  prognosis  is  very  good  indeed,  as  long  as  there 
is  no  fever.  The  dyspnea  and  discomfort  which  this  disease  causes 
for  years  are  bearable  by  the  average  patient.  But  as  soon  as  fever 
makes  its  appearance,  and  persists  for  some  time,  the  prognosis  is 
that  of  chronic  phthisis  which  will  soon  be  discussed. 

The  influence  of  the  patient's  age  on  prognosis  has  already 
been  discussed  in  the  chapters  dealing  with  tuberculosis  in  children 
(p.  374  and  391),  and  in  the  aged  (p.  394). 

The  most  important  form  of  phthisis,  that  of  the  most  common 
chronic  type,  is  the  disease  in  which  the  prognosis  is  very  difficult  to 
formulate  in  the  individual  case.  We  may  be  able  to  prove  statistic- 
ally that  a  certain  percentage  of  cases  recover  completely;  another 
percentage  will  survive  so  many  years;  still  another  percentage  will 
succumb  within  one  or  two  years,  etc.  But  in  the  practice  of  medicine 
we  deal  with  individual  cases  and  statistics  count  for  naught. 

In  the  individual  case  the  outcome  of  the  disease  depends  on  so 
many  complex  and  variable  factors,  that  it  is  often  very  difficult  to 
formulate  a  prognosis.  Indeed,  we  see  that  the  most  desperate  case, 
slowly  or  suddenly,  with  or  without  any  discoverable  reason,  takes  a 
turn  to  the  better  and  recovers.  We  see  others  who  drag  along  for 
years,  living,  but  they  do  not  recover.  Still  others,  in  whom  the 
general  condition  has  been  quite  or  altogether  favorable,  suddenly 
take  a  turn  to  the  worse  and  the  patient  is  carried  off  within  a  few 
weeks  or  months. 

For  these  reasons  we  must  enter  into  the  elements  of  prognosis  of 
chronic  phthisis  in  greater  detail. 

Prognostic  Significance  of  the  Patient's  History.— Many  authors 
have  stated  that  patients  with  a  family  history  of  tuberculosis  are  more 
likely  to  run  an  unfavorable  course  than  those  derived  from  non- 
phthisical  stock.  A  consideration  of  the  facts  brought  together  in 
Chapter  V  will  show  that  this  is  a  fallacious  view.  The  patient  was 
undoubtedly  infected  during  childhood.  Had  he  suffered  a  massive 
infection  during  infancy  he  would  have  succumbed  to  some  acute 


426  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

form  of  tuberculosis.  The  fact  that  he  survived  the  primary  infection 
proves  that  it  was  mild;  this  is  also  the  reason  why  he  now  suffers 
from  chronic  phthisis,  and  not  from  an  acute  form  of  the  disease. 
Indeed,  patients  showing  signs  of  some  local  tuberculous  lesion  at  an 
earlier  age  usually  have  a  slow,  sluggish  form  of  phthisis  lasting  for 
many  years.  Many  authors  have  also  calculated  that  the  average 
duration  of  a  phthisical  patient  with  a  family  history  of  tuberculosis 
is  longer  than  in  one  derived  from  robust  stock.  This  is  best  seen  in 
the  acuteness  of  phthisis  in  persons  who  have  just  emigrated  from_ 
rural  districts  into  large  cities. 

Experience  teaches  that  the  prognosis  is  not  different  in  adults  who 
are  derived  from  phthisical  stock  than  in  those  who  are  not.  The 
slight  differences  that  have  been  discerned  appear  to  be  rather  in 
favor  of  the  former. 

Sex. — It  appears  that  the  prognosis  is  more  favorable  in  women  than 
in  men.  A  man  acquiring  tuberculosis  is  apt  to  continue  working  and 
thus  aggravate  the  prognosis  while  a  woman,  who  is  usually  not  the 
bread-winner,  is  more  likely  to  abstain  from  overexertion,  which  is 
such  an  important  element  in  the  treatment  of  this  disease.  On  the 
other  hand,  pregnancies,  labor,  and  lactations  are  apt  to  aggravate 
the  prognosis  in  women.  In  fact,  it  has  been  my  experience  that  the 
prognosis  of  phthisis  in  women  is  better  in  those  who  are  unmarried 
than  in  those  who  are  married.  Women  are  less  likely  to  succumb 
to  some  of  the  more  serious  complications  of  phthisis,  such  as  hemor- 
rhage, pneumothorax,  etc.  They  also  less  often  suffer  from  laryngeal 
tuberculosis. 

The  Onset  of  the  Disease. — In  cases  with  a  sudden  onset  the  prog- 
nosis is  worse  than  in  those  in  whom  the  disease  came  on  insidiously. 
Even  the  fact  that  the  former  are  more  apt  to  take  strong  measures 
to  prevent  the  activity  of  the  process  does  not  counterbalance  the 
seriousness  of  an  acute  onset,  excepting  when  the  suddenness  refers 
merely  to  an  initial  pulmonary  hemorrhage.  An  acute  onset  means 
severe  constitutional  and  toxic  symptoms,  low  powers  of  resistance, 
and  the  process  in  the  lungs  extends  very  quickly,  so  that  in  a  short 
time  quite  large  portions  of  one  or  both  lungs  are  affected. 

Those  beginning  with  hemoptysis  have  usually  a  better  outlook 
than  others.  The  reason  is  not  clear.  Perhaps  the  dramatic  onset 
frightens  the  patient  and  he  is  apt  to  institute  proper  treatment  even 
if  he  feels  well  after  the  cessation  of  the  bleeding,  while  patients  with 
mild  symptoms  but  without  hemoptysis  may  continue  at  work  till 
the  disease  is  aggravated.  But  this  does  not  explain  all  cases.  It 
seems  that  hemoptysis  has  very  often  a  good  influence  on  the  prog- 
nosis of  phthisis  at  any  stage  of  the  disease  and  many  patients  feel 
much  better  after  a  brisk  hemorrhage  (see  p.  201).  The  cases  marked 
by  an  onset  with  pleurisy,  dry  or  moist,  have,  as  a  rule,  a  better  prog- 
nosis than  others,  as  has  already  been  stated  (p.  89).  It  has  been 
observed  that  patients  who  are  only  slowly  regaining  their  health  after 


SIGNIFICANCE  OF   THE  ACTIVITY  OF  THE  DISEASE      427 

an  attack  of  pleurisy,  are  pale  and  emaciated,  and  are  more  likely  to 
develop  active  and  progressive  phthisis  than  those  who  recover 
quickly  and  soon  regain  their  former  health. 

Prognostic  Significance  of  the  Activity  of  the  Disease. — We  have 
seen  throughout  this  book  that  the  activity  of  the  process  in  the  lung 
has  a  greater  influence  on  the  ultimate  outcome  than  the  stage  of 
the  disease.  The  activity  is  best  studied  by  a  careful  consideration  of 
general  or  constitutional  symptoms.  Of  these,  fever  is  the  most 
important.  There  is  no  active  tuberculosis  without  pyrexia.  The 
afebrile  cases  discussed  elsewhere  are  rather  uncommon  and  it  is  a 
fact  that  the  prognosis  is  rather  good,  as  long  as  fever  is  lacking.  Each 
turn  for  the  worse,  each  complication,  is  accompanied  by  a  rise  in  the 
temperature. 

In  active  disease  the  prognosis  is  unfavorable  in  direct  ratio  to 
the  height  and  duration  of  the  fever.  Every  extension  of  the  lesion 
manifests  itself  by  increased  pyrexia;  persistence  of  pyrexia,  despite 
rigid  rest  in  bed,  is  pathognomonic  of  low  resistance;  the  reverse 
type  of  fever,  in  which  the  highest  point  is  reached  in  the  morning 
instead  of  the  afternoon  or  evening,  is  of  grave  prognostic  significance 
—it  may  be  an  indication  of  an  invasion  of  both  lungs  by  tubercles. 
On  the  other  hand,  moderate  fever,  less  than  101°  F.  dropping  down  to 
normal  or  subnormal  in  the  morning,  is  rather  favorable.  In  other 
words:  The  higher  the  morning  temperature,  the  nearer  it  approaches 
the  evening  temperature,  the  worse  the  prognosis.  Hectic  fever,  with 
normal  and  subnormal  temperature  in  the  morning,  but  which  rises 
high  in  the  afternoon  and  evening,  is  of  grave  prognostic  significance. 
If  it  lasts  for  more  than  a  month,  the  patient  will  not  survive.  He 
may  last  or  even  improve  for  a  time,  but  he  will  not  recover. 

A  normal  temperature  throughout  the  day  and  night  is  a  good  sign; 
when  accompanied  by  a  good  appetite,  gain  in  weight,  diminution  in 
the  cough  and  expectoration,  etc.,  it  is  an  indication  of  healing  of  the 
lesion.  If  fever  only  ensues  after  exertion  or  excitement,  the  prog- 
nosis is  very  good  indeed,  provided  proper  treatment  is  instituted.  It 
is  for  this  reason  that  most  who  have  new  and  infallible  remedies  for 
phthisis  ask  for  just  this  sort  of  cases  on  which  to  try  the  treatment. 
The  vast  majority  recover  under  any  treatment,  provided  good 
nourishment  and  rest  is  part  of  the  proceeding. 

Indeed  we  can,  in  most  cases,  formulate  our  prognosis  by  a  careful 
study  of  the  temperature  curve  for  a  few  weeks.  Of  course  we  may  on 
rare  occasions  err  by  putting  implicit  faith  in  the  temperature  curve, 
but  the  proportion  of  errors  will  be  less  than  when  we  attempt  to 
formulate  it  on  other  data,  especially  on  the  stage  of  the  disease,  or 
the  findings  on  physical  examination. 

For  this  reason,  a  prognosis  in  phthisis  should  not  be  gimn  after  a 
single  examination  of  the  patient.  It  is  required  that  the  temperature 
of  the  patient  should  be  studied  for  at  least  two  weeks  before  attempt- 
ing to  forcast  the  outlook. 


428  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

The  prognostic  significance  of  the  pulse  should  be  considered. 
Excepting  in  heart  disease  and  hyperthyroidism,  no  disease  can  be 
evaluated  prognostically  with  the  same  degree  of  accuracy  by  the 
pulse  rate  as  chronic  phthisis.  Incipient  cases  with  a  pulse  not  above 
80  per  minute  have  an  excellent  outlook.  Tachycardia  is  an  indication 
of  acuteness  of  the  process,  or  low  resistance,  or  both.  Patients  who 
have  apparently  recovered  but  remained  with  a  rapid  pulse,  have  a 
very  poor  outlook.  The  outlook  is  good  in  chronic  cases  with  slow 
pulse. 

Of  the  other  constitutional  symptoms  which  give  us  prognostic 
hints,  the  state  of  the  gastro-intestinal  tract  is  of  great  importance. 
Patients  with  good  appetite  and  who  digest  and  assimilate  their  food 
well,  recover,  even  when  they  have,  for  the  time  being,  some  fever 
every  afternoon.  Persistent  anorexia  and  gastro-intestinal  disturb- 
ances are  of  grave  prognostic  significance.  Gain  in  weight  in  afebrile 
patients  with  good  appetites  is  a  good  sign.  But  occasionally  we  meet 
a  patient  who  holds  his  own  or  even  gains  despite  the  fever.  In  such 
cases  the  thermometer  should  be  our  guide,  and  not  the  scale. 

Hemoptysis  has  no  influence  on  the  course  and  prognosis  of  the 
disease  in  the  vast  majority  of  cases.  The  initial  hemoptyses  are 
rather  salutary,  as  was  stated  above.  No  patient  has  succumbed  to  a 
really  initial  hemoptysis.  Ninety-eight  per  cent,  of  cases  of  advanced 
disease  recover  from  hemorrhages.  But  in  cavitary  cases,  which  may 
or  may  not  be  doing  well,  a  brisk  hemoptysis  may  unexpectedly  kill  the 
patient.  If  in  the  average  case  the  hemoptysis  is  not  accompanied 
by  fever,  or  the  fever  lasts  only  a  few  days  after  the  cessation  of 
active  bleeding,  the  prognosis  is  good.  But  if  pyrexia  continues  it 
may  point  to  acute  pneumonic  phthisis  or  tuberculous  broncho- 
pneumonia which  is  almost  invariably  fatal.  In  these  cases  the 
hemoptysis  is  indirectly  responsible  for  the  fatal  issue. 

Prognostic  Significance  of  Complications. — The  presence  of  com- 
plications, tuberculous  and  others,  modifies  the  prognosis  perceptibly. 
Thus,  laryngeal  and  intestinal  tuberculosis  aggravate  the  prognosis. 
Though  many  recoveries  are  seen  in  patients  with  these  affections, 
yet  in  the  individual  case  we  must  not  give  a  favorable  prognosis  in 
those  who  show  positive  proof  of  laryngeal  or  intestinal  complication. 
With  advanced  laryngeal  disease,  manifesting  itself  in  aphonia,  dys- 
phagia, etc.,  a  fatal  issue  is  to  be  expected.  The  same  is  true  of 
diarrhea  which  lasts  more  than  a  month.  We  occasionally,  however, 
see  patients  with  profuse  diarrhea  lasting  for  several  months.  But 
they  never  recover.  Blood  in  the  stools  is  another  unfavorable  sign. 
Ischiorectal  abscess  is  itself  an  indication  of  intestinal  tuberculous 
ulceration  and  is  of  unfavorable  prognostic  significance. 

Pleurisy  is  not  invariably  an  unfavorable  complication.  The  dry 
form  occurs  in  nearly  all  chronic  cases  and  has  a  rather  salutary 
influence  on  the  pulmonary  lesion;  it  is  also  a  good  preventive  of  spon- 
taneous pneumothorax.    Pleural  effusions  are  serious,  though  in  many 


SIGNS  FOUND  ON  PHYSICAL  EXAMINATION  429 

cases  they  have  a  good  influence  on  the  basic  disease.  We  have 
already  shown  that  they  occasionally  promote  the  healing  of  the  lesion 
in  the  lung  by  compression.  But  in  bilateral  lesions  the  side  with  a 
free  pleura  is  likely  to  suffer  from  an  extension  of  the  tuberculous 
process  and  the  outlook  is  gloomy. 

Empyema  is  a  very  bad  complication.  No  recovery  is  to  be  expected. 
The  patient  may  last  for  months,  but  he  will  not  recover.  On  exceed- 
ingly rare  occasions  the  pus  breaks  through  a  bronchus  and  is  expec- 
torated. But  even  here  the  ultimate  outlook  is  bad,  because  of  the 
amyloid  degeneration  of  the  viscera  and  the  general  malnutrition 
caused  by  the  prolonged  suppuration. 

Spontaneous  pneumothorax  is  fatal  in  95  per  cent,  of  cases  within 
one  month  of  its  occurrence.  The  exceptions  have  already  been 
mentioned. 

Tuberculosis  of  the  kidney  is  of  unfavorable  import. 

Of  non-tuberculous  complications  we  may  mention  influenza.  This 
disease  is  more  often  diagnosed  in  tuberculous  patients  than  facts 
would  warrant.  An  increase  in  the  cough,  pyrexia,  etc.,  due  to  an 
exacerbation  of  the  tuberculous  process,  is  apt  to  be  attributed  to  in- 
fluenza by  patients  and  physicians.  But  when  it  does  occur,  it  is  apt 
to  wake  up  quiescent  lesions  in  the  lungs.  Lobar  pneumonia  occasion- 
ally occurs  in  phthisical  patients.  In  the  cases  observed  by  the  author 
the  outcome  depended  on  the  condition  of  the  tuberculous  lung.  Those 
with  slight  quiescent  lesions  may  pass  through  an  attack  of  pneu- 
monia, recover,  and  the  phthisis  should  pursue  its  course  as  if  no  such 
complication  had  occurred.  But  in  patients  with  extensive  tubercu- 
lous lesions,  reduced  in  vitality,  the  pneumonia  is  the  last  straw  and 
the  patient  is  carried  off  within  a  week. 

We  often  meet  other  non-tuberculous  diseases  in  patients  suffering 
from  phthisis.  Such  as  necessitate  an  operation  with  the  administra- 
tion of  a  general  anesthetic  are  dangerous,  and  it  has  been  my  rule  to 
urge  local  anesthesia  whenever  feasible  in  operations  on  tuberculous 
subjects. 

Pr"egnancy  is  a  grave  complication  of  phthisis,  and  in  incipient 
cases  it  is  advisable  to  induce  abortion  whenever  it  occurs.  For  this 
reason  it  is  urgent  that  married  phthisical  women  should  be  instructed 
in  the  methods  of  prevention  of  conception.  During  pregnancy  the 
patient  may  feel  well,  even  better  than  before  conception  has  taken 
place.  But  after  childbirth  there  is  often  a  reactivation  of  the  tuber- 
culous process  and  an  acute  course  of  the  disease. 

Prognostic  Significance  of  Signs  found  on  Physical  Examination. — 
We  have  already  mentioned  the  faflacy  of  formulating  the  prognosis  of 
phthisis  solely  on  the  findings  by  physical  examination.  There  are 
cases  showing  physical  signs  indicating  that  we  are  dealing  with 
incipient,  or  first-stage  cases  of  the  American  or  Turban's  classification, 
yet  the  prognosis  is  very  unfavorable.  Indeed  the  most  unfavorable 
prognosis  should  be  given  in  cases  showing  marked  constitutional 


430  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

symptoms  which  are  out  of  proportion  to  the  findings  on  physical 
examination. 

It  may  be  stated  that  generally  the  extent  of  pulmonary  involve- 
ment is  of  more  importance  than  the  stage  to  which  the  lesion  has 
advanced.  Cavitation  in  one  lobe  is  of  less  danger  than  infiltration 
of  two  or  three  lobes.  J.  Edward  Squire  gives  the  following  table 
embracing  2720  cases  of  phthisis  showing  the  relation  of  improvement 
to  the  number  of  lobes  involved: 

Much  improved.  Improved.  Total  improved. 

Lobes  affected.  Cases.  Per  cent.  Per  cent.  Per  cent. 

1  .      .      .  877  58.38  28.62  87.00 

2  .      .      .  1015  37.83  34.67  72.. 50 

3  .      .      .  515  22.52  35.53  58.03 

4  ...  277  15.16  29.24  44.40 

The  fear  and  apprehension  entertained  by  both  the  profession  and 
the  patient  for  "holes  in  the  lung"  are  based  on  misconceptions  of  the 
pathology  of  phthisis.  The  fact  is  that  the  most  dangerous  cases  of 
progressive  phthisis  are  fatal  before  cavities  are  formed.  This  is  the 
case  with  miliary  tuberculosis  and,  to  a  certain  extent,  with  acute 
pneumonic  phthisis.  If  a  tuberculous  lesion  in  the  lung  does  not  cica- 
trize quickly,  the  best  that  can  happen  to  the  patient  is  that  a  cavity 
should  form.  A  cavity  is  proof  that  the  organism  is  in  possession  of 
strong  powers  of  resistance,  in  fact  of  immunity;  otherwise  the 
lesion  would  spread.  The  difference  between  active  phthisis  with 
cavity  formation  and  without  such  occurrence  is  analogous  to  that 
between  general  septicemia  and  abscess.  In  the  latter  case  the  disease 
is  localized  and  circumscribed  and,  when  drained,  the  danger  is  not  very 
great.  A  cavity  has,  in  fact,  been  defined  as  a  tuberculous  abscess 
which  is  drained  through  a  fistulous  opening  into  a  bronchus. 

It  may  be  stated  that  the  dangers  of  tuberculous  cavities  vary 
inversely  with  the  time  it  takes  for  their  formation.  The  sooner  they 
are  produced  the  worse  the  prognosis;  the  slower  they  develop,  the 
better  the  ultimate  outlook.  In  very  acute  forms  of  phthisis  cavitation 
is  very  rare.  The  prognosis  is  gloomy  with  or  without  localized 
destruction  of  pulmonary  tissue.  In  adults,  such  cases  are  compara- 
tively rare,  but  in  infants  rapid  cavity  formation  is  seen  at  times  and 
the  termination  is  almost  invariably  fatal.  In  subacute  forms  of 
phthisis,  in  which  excavations  are  apt  to  form  very  rapidly,  the  prog- 
nosis is  unfavorable,  unless  the  cavity  is  rather  small.  In  the  latter 
case  the  disease  may  be  attenuated  and  subsequently  pursue  a  chronic 
course  with  the  sequestration  and  expulsion  of  the  affected  area. 
Excavation  is  then  the  first  step  toward  the  diminution  of  the 
acuteness  of  the  process  in  the  lung.  The  general  symptoms  may  be 
ameliorated,  as  after  the  evacuation  of  an  abscess. 

In  chronic  phthisis  excavations,  even  when  extensive,  are  com- 
patible with  a  long  and  efficient  life.  These  caAities  are  surrountled 
by  more  or  less  dense  fibrous  capsules  which  limit  their  extension  and 


SPECIAL   TESTS  431 

are  drained  through  fistulous  tracts  communicating  with  bronchi. 
As  long  as  the  secretions  are  eliminated  by  expectoration,  the  patient 
may  feel  quite  comfortable  for  years.  The  cavities  may  even  heal, 
as  was  already  shown  (see  p.  137).  When  small,  they  may  be  obliter- 
ated by  granulations  or  by  calcification  of  their  contents.  Larger 
excavations  may  shrink  or,  even  when  remaining  of  large  dimensions, 
they  may  become  altogether  benign  after  the  necrotic  tissue  has  been 
expelled.  They  are,  however,  a  constant  source  of  danger  for  metas- 
tatic auto-infection  or  copious  hemorrhages. 

In  my  experience  patients  with  right-sided  lesions  of  this  type  are 
more  likely  to  recover  than  those  with  left-sided  lesions.  In  the  former 
the  constitutional  symptoms,  especially  dyspnea,  tachycardia,  etc.,  may 
improve  or  disappear  after  the  formation  of  a  chronic  cavity  and  the 
disappearance  of  the  pyrexia.  Even  dextrocardia  may  be  well  borne. 
But  in  left-sided  lesions  the  heart  is  pulled  over  to  the  left  and  up- 
ward, and  the  patient  remains  with  tachycardia  and  is  distressingly 
short-winded.  Though  he  may  last  for  years,  he  never  regains 
efficiency. 

In  chronic  cases  in  which  the  formation  of  a  cavity  is  slow,  the 
prognosis  is  rather  good.  In  fact,  cavity  formation,  as  we  have  already 
shown,  is  a  sign  of  immunity.  Those  with  little  or  no  resistance 
succumb  before  there  is  an  opportunity  for  cavity  formation. 

These  cavities  are  surrounded  by  dense  fibrous  capsules  which  limit 
their  progress  or  extension,  and  they  may  be  harmless  for  long  periods 
of  years.  Communicating  with  bronchi  which  permit  the  expulsion 
of  the  morbid  secretions  forming  on  the  ulcerated  wall,  they  often 
pursue  an  apyretic  course.  Some  even  have  smooth  and  glittering 
walls  without  any  lymph  spaces  and  the  toxic  products  within  them 
cannot  be  absorbed.  We  meet  with  cases  in  which  even  the  tubercle 
bacilli  disappear  from  the  sputum  and  the  prognosis  is  the  same  as 
in  bronchiectasis. 

There  are  many  of  this  class  of  patients  who,  despite  having  more  or 
less  extensive  excavations,  live  for  many  years  without  pronounced 
inconvenience;  in  faqt  some  consider  themselves  fairly  healthy  and 
attend  to  their  callings  or  even  to  manual  labor.  Their  main  trouble 
consists  in  a  proclivity  to  "catch  cold,"  and  only  on  such  occasions 
do  they  call  on  their  physicians  for  relief. 

Generally  speaking  tuberculous  cavities  are  indications  of  chron- 
icity  of  the  tuberculous  process  in  the  lung,  showing  that  the  resisting 
forces  are  active  and  as  such  are  of  better  prognostic  augury  than 
many  active  incipient  cases. 

Patients  are  to  be  told  that  the  "holes"  in  their  lungs  'per  se  are 
not  as  dangerous  as  they  believe.  That  fever,  anorexia,  etc.,  are 
more  dangerous,  They  may  live  and  can  be  active  with  cavities  for 
many  years. 

Special  Tests. — Various  attempts  have  been  made  to  find  tests  of 
the  severity  of  phthisis  by  examination  of  the  blood,  urine,  etc.    We 


432  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

have  already  seen  that  Arneth's  blood  picture  is  not  as  reliable  as  some 
would  lead  us  to  believe  (see  p.  225).  Ehrlich's  diazo-reaction  was 
at  one  time  considered  reliable  in  indicating  the  severity  of  phthisis. 
But  it  appears  that  it  is  positive  in  cases  which  are  otherwise  indicating 
their  progressive  tendencies.  In  incipient  cases  it  is  as  a  rule  negative, 
but  I  have  met  with  cases  in  which  it  was  positive,  yet  the  case  went 
on  to  uneventful  recovery.  It  appears  that  at  present  very  few  place 
great  reliance  on  this  test. 

Moritz  Weisz^  found  that  urochromogen  is  the  principal  substance 
which  causes  the  diazo-reaction  and  suggested  that  his  test  is  superior 
to  the  latter.  I  have  used  of  late  Weisz's  urochromogen  test  and  found 
it  superior  to  the  diazo-reaction  in  indicating  the  prognosis  of  active 
phthisis.  It  is  thus  performed:  Into  each  of  two  small  test  tubes  are 
put  8  c.c.  of  urine  and  2  c.c.  of  distilled  water  are  added;  now,  to  one 
tube  which  is  to  be  tested  for  urochromogen,  3  drops  of  1  to  1000 
solution  of  potassium  permanganate  are  added,  the  tube  is  shaken 
thoroughly  and  compared  with  the  control  tube.  The  appearance  of 
the  faintest  yellow  color  shows  the  presence  of  urochromogen  and  is 
easily  detected  by  comparing  with  the  control  tube,  to  which  no 
potassium  permanganate  is  added.  The  test  is  read  positive,  however, 
only  when  the  solution  stays  clear. 

In  this  country  Heflebower,^  and  J.  Metzger  and  S.  H.  Watson^ 
have  reported  that  this  test  is  a  reliable  guide  in  estimating  the  activ- 
ity of  the  tuberculous  process  and  gives  indication  as  to  prognosis.  I 
find  that  it  is  positive  during  acute  exacerbations  of  the  disease  and  is 
usually  negative  in  incipient  cases  or  even  in  quiescent  cases.  In  acute 
progressive  cases  it  is  found  positive  and  it  becomes  more  and  more 
intense  with  the  extension  of  the  disease.  It  is  negative  in  most 
favorable  cases. 

The  complement-fixation  test,  which  has  of  late  been  used  in  the 
diagnosis  of  tuberculosis  with  doubtful  results  (see  p.  324)  has  been 
found  by  some  authors  to  have  some  prognostic  value.  Debains 
and  Jupille^  report  that  in  active  incipient  and  hopeful  cases  of  phthisis 
the  reaction  is  usually  positive,  while  in  advanced  cases,  with  pro- 
nounced emaciation  the  reaction  is  often  feeble  or  altogether  negative. 
They  try  to  explain  these  phenomena  on  the  assumption  that  in  pro- 
gressive and  advanced  phthisis  the  antibodies  in  the  serum  have  already 
been  bound  or  neutralized  by  the  substances  produced  by  the  tubercle 
bacilli.  They  also  found  that  in  experimental  tuberculosis  in  rabbits 
complement-fixation  activity  goes  hand-in-hand  with  the  resistance  of 
the  animal.  On  the  other  hand,  in  tuberculous  pleurisy  with  eftusion 
negative  reactions  were  mostly  found,  and  this  form  of  the  disease 
cannot  be  considered  as  of  especially  unfavorable  prognosis.     Most  of 

1  Miinch.  med.  Wchnschr.,  1911,  Iviii,  1348. 

2  Amer.  Jour.  Med.  Sciences,  1912,  cxliii,  221. 

3  Jour.  Amer.  Med.  Assn.,  1914,  Ixii,  1886. 

*  Compt.  rend.  Soc.  de  biol.,  1914,  Ixxvi,  199. 


ANTAGONISTIC  DISEASES  433 

the  work  along  these  Hues  was  done  by  Besredka/  who  in  a  recent 
paper  reports  that  the  reaction  is  uniformly  positive  in  early  cases  of 
phthisis;  in  moderately  advanced  cases  it  is  positive  in  the  majority. 
With  the  advance  of  the  disease  the  reaction  becomes  feeble,  and 
finally  in  the  terminal  stages  of  phthisis  it  becomes  negative.  With 
Manoukhine  he  regards  a  negative  reaction  in  advanced  phthisis  as 
a  sign  of  approaching  death. 

These  findings  are  worthy  of  further  investigation  because  a  prog- 
nostic test  in  phthisis  is  almost  as  important  as  a  diagnostic  test. 

Influence  of  Economic  Conditions  of  the  Patients  on  the  Prognosis. 
— -The  occurrence  of  phthisis  is  in  itself  an  indication  of  poverty.  To 
be  sure,  we  meet  with  numerous  rich  consumptives,  but  economic 
prosperity  is  not  always  an  indication  of  rational  life,  proper  food, 
regular  houfs,  avoidance  of  physical  and  mental  overexertion,  etc. 
But  in  a  given  case  of  phthisis  the  prognosis  is  often  influenced  more 
by  the  social  and  economic  condition  of  the  patient  than  by  any  other 
single  factor.  After  all,  phthisis  is  the  most  expensive  of  diseases 
because  it  disables  the  patient  for  a  long  period  of  time  and  requires 
expensive  treatment,  including  nourishment,  a  favorable  home,  etc. 

The  patients  who  can  afford  to  bear  the  expense  are  more  likely  to 
recover  than  those  who  cannot.  The  artisan  often  has  a  family 
depending  on  him  for  support,  and  he  is  likely  to  keep  at  work  while 
sick,  till  the  disease  has  progressed  to  a  stage  where  he  can  do  no  more 
and  drops  from  sheer  exhaustion.  It  is  in  these  cases  that  the  insti- 
tutions, as  well  as  the  social  service  of  modern  enlightened  commu- 
nities do  considerable  to  improve  the  prognosis  of  phthisis.  But  it 
must  always  be  borne  in  mind  that  these  agencies  can  do  much  better 
than  merely  give  advice  about  the  dangers  of  living  with  tuberculous 
persons  in  one  home,  and  distribute  sputum  cups.  If  they  do  only  this, 
the  prognosis  is  often  aggravated  because  the  patient  is  at  times 
treated  like  a  pariah  by  his  relatives  and  friends  who  are  frightened 
by  the  numerous  "visitors,"  the  social  workers,  nurses,  physicians, 
and  others.  I  have  seen  families  broken  up  in  this  manner;  families 
in  which  there  were  no  infants,  and  there  was  no  reason  to  fear  dissem- 
ination of  the  disease.  But  what  is  of  most  importance,  the  patient, 
deprived  of  the  comfort  of  a  good  home,  becomes  despondent  and  the 
lesion  progresses  more  quickly  than  it  would  otherwise. 

Antagonistic  Diseases.— We  have  already  seen  that  individuals 
sufi^ering  from  mitral  stenosis  are  less  likely  to  develop  phthisis,  despite 
the  fact  that  they  are  just  as  much  exposed  to  infection  as  others 
(p.  91).  In  fact,  it  appears  that  a  hypertrophied  heart  due  to  any 
cause  is  more  or  less  of  a  protection  against  phthisis;  if  the  latter 
does  occur,  it  runs  a  milder  course  and  tends  to  heal. 

Phthisis  is  characterized  by  arterial  hypotension,  and  this  may  be 
the  reason  why  it  is  so  rare  in  patients  with  arteriosclerosis,  and 

1  Ann.  de  I'lnst.  Pasteur,  1914,  xxviii,  569;  Compt.  rend.  Soc.  de  biol.,  1914,  Ixxxvi,  197, 

28 


434  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

when  it  does  occur  it  runs  a  benign  course.  In  fact,  it  is  rare  to  find 
arteriosclerosis  in  phthisical  patients  with  albuminuria,  casts,  etc., 
indicating  that  they  have  chronic  nephiitis.  Similarly  persons 
suffering  from  interstitial  or  parenchymatous  nepliritis  of  a  chronic 
t}q)e  become  phthisical  only  rarely.  In  the  aged — -arteriosclerotics^ 
phthisis  runs  an  exceedingly  chronic  course,  as  we  have  already 
shown. 

French  authors  have  described  an  antagonism  between  the  arth- 
ritic and  the  phthisical  diatheses.  M.  Raynaud  noted  that  in  gouty 
individuals  phthisis,  when  it  does  occur,  has  a  better  outlook  than  in 
the  average  patient.  The  lesion  is  usually  limited  to  one  apex  and 
runs  a  latent  course.  A  marked  tendency  to  fibrosis  is  seen  in  and 
around  the  lung  lesion.  Well-nourished  consumptives — the  "fat 
consumptives"  already  mentioned — are  mainly  found  among  arthritic 
subjects,  or  persons  of  arthritic  stock,  and  also  among  those  who  were 
scrofulous  during  early  childhood,  as  has  been  shown  by  Pidoux,^ 
Sokolowski,^  and  others.  Even  when  they  suffer  from  hemoptysis, 
which  is  not  rare,  they  recuperate  rather  quickly  and  are  none  the 
worse  for  their  experience.  Lemoine^  maintains  that  tuberculous 
arthritics  supply  the  main  contingent  of  the  curable  cases  of  phthisis, 
and  among  them  are  those  who,  despite  tuberculosis,  reach  an  advanced 
age.  The  nutrition  of  the  patient  is  also  affected  to  a  lesser  degree  in 
scrofulous  individuals  when  they  become  phthisical,  even  when  the 
process  is  extensive.  He  believes  that  the  tendency  to  evanescent 
congestive  conditions  promotes  sclerosis  of  the  lesion.  But  we  now 
have  a  better  explanation.  Scrofulous  individuals  are  endowed  with 
a  high  degree  of  immunity  against  tuberculosis. 

English  writers,  who  have  seen  many  gouty  patients,  confirm 
these  observations.  J.  E.  Pollock  believed  that  "gout,  like  rheu- 
matism, when  the  specific  attack  of  the  disease  is  developed  in  a 
case  of  tubercle,  retards  the  latter."  Sir  Dyce  Duckworth  supposes 
gout  or  the  gouty  diathesis  is  antagonistic  to  phthisis.  F.  Parkes 
Weber^  suggests  that  the  resistance  of  gouty  persons  toward  tubercu- 
losis is  probably  partly  due  to  the  meat  food  (butcher's  meat,  eggs,  and 
all  animal  protein  foods)  which  most  persons  with  acquhed  goutiness 
have  been  accustomed  to  indulge  in  freely  dm'ing  most  of  their  lives. 
He  suggested  that  there  might  be  some  substance  circulating  in  the 
blood  in  gouty  persons  in  minute  quantities,  yet  sufficient  to  have 
an  antagonistic  action  toward  the  growth  of  tubercle  and  that  perhaps 
this  was  likewise  the  case  in  persons  taking  an  unusual  amount  of  food, 
which  might  partly  account  for  the  good  results  following  the  extra 
feeding  of  phthisical  patients,  when  duly  assisted  by  hygienic  sur- 
roundings.    "Great  meat  eaters,  if  not  alcoholic,  rarely,  even  in  the 

1  Etudes  generales  et  pratiques  sur  la  phtisie,  Paris,  1873. 

2  Deut.  Arch.  f.  klin.  Med.,  xlvii,  558. 

3  Semaine  Medicale,  1900.  xx,  103. 
*  Lancet,  1904,  i,  924. 


PROGNOSIS  IN  ARRESTED'  DISEASE  435 

most  unhygienic  surroundings,  become  phthisical."  Sir  Andrew  Clark/ 
Herman  Weber,-  and  others  noted  the  antagoni.sm  between  gout 
and  phthisis.  Weber  even  urges  the  acceptance  as  insurance  risks 
of  persons  affected  with  fibroid  phthisis,  also  such  as  have  gout 
and  tuberculosis,  because  they  have  great  resistance  against  the 
ravages  of  phthisis.  Bandelier  and  Ropke  found  that  in  individuals 
with  a  disturbed  purin  metabolism,  phthisis  is  always  chronic  or  latent 
and  shows  strong  tendencies  to  fibrosis.  Raw^  regard^s  the  gouty 
diathesis  as  antagonistic  to  tuberculosis  and  he  found  that  the  blood  of 
a  gouty  person  is  not  a  suitable  medium  in  which  the  bacilli  will  flourish. 

From  personal  experience  the  writer  is  inclined  to  agree  with  Mayer^ 
that  the  antagonism  applies  only  to  constitutional  gout,  while  gout 
resulting  from  plumbism  rather  favors  the  development  of  phthisis. 
I  have,  in  fact,  seen  many  cases  of  subacute  phthisis,  running  a  rapid 
course  in  house  painters  who  have  for  years  suft'ered  from  lead  poison- 
ing and  atypical  gout.  Most  of  them,  however,  suffer  from  fibroid 
phthisis. 

It  also  appears  that  syphilis,  while  not  antagonistic  to  the  devel- 
opment of  phthisis,  yet  influences  the  latter  disease  so  that  it  runs  a 
mild  course,  showing  strong  tendencies  to  fibrosis.  Fibroid  phthisis 
is  very  often  seen  in  old  luetics,  and  antisyphilitic  treatment  has  a 
good  influence  on  both  diseases.  On  the  other  hand,  when  a  consump- 
tive acquires  syphilis  both  diseases  are  apt  to  run  a  rapid,  or  even  a 
malignant  course. 

Prognosis  in  Arrested  Disease. — We  have  seen  that  only  lesions 
of  abortive  tuberculosis  are  completely  healed  by  cicatrization  and 
calcification.  But  this  form  of  the  disease  is  not  recognized,  as  a  rule, 
during  its  activity,  and  the  prognosis  is  good  at  all  events.  It  is 
different  with  chronic  phthisis  which  has  lasted  for  some  time  and 
finally  there  is  an  abatement  in  the  constitutional  symptoms  and  the 
patient  is  considered  cured. 

Cure  by  restitutio  ad  integrum  is  out  of  the  question  in  these  cases. 
The  cicatrized  and  calcified  foci  usually  contain  virulent  tubercle 
bacilli  which  may  at  any  time  become  active  again,  flaring  up  the  lesion, 
or  causing  metastatic  auto-infection.  Experience  has  taught  that  in 
the  vast  majority  of  cases  these  patients  attain  but  "quiescence,"  and 
the  term  "arrested  disease,"  which  has  recently  been  substituted  for 
the  term  "cured,"  which  was  formerly  in  vogue,  is  proper.  The 
patient  is  justified  in  asking  for  an  opinion  whether  this  arrested^con- 
dition  is  likely  to  be  lasting,  or  whether  he  will  sooner  or  later  suffer 
from  a  recrudescence  of  the  symptoms  of  phthisis,  a  relapse,  which  is 
in  fact  an  acute  or  subacute  exacerbation.  In  other  words,  is  the 
arrest  of  the  disease  an  indication  of  a  more  or  less  permanent  freedom 

1  Trans  Med.  Society,  London,  1889,  xiii,  9. 

2  Medical  Examiner,  1898,  p.  122. 

3  Tuberliulosis,  1911,  x,  169. 

*  Ztschr.  f.  Tuberkulose,  1914,  xxiii,  243. 


436  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 

from  tuberculous  sickness,  or  is  it  merely  a  long  remission  in  the 
progress  of  the  disease? 

These  problems  can  be  solved  by  a  consideration  of  the  physical 
signs  found  in  the  chest,  but  with  greater  certainty  when  the  consti- 
tutional symptoms  are  considered. 

Physical  exploration  of  the  chest  discloses  usually  signs  of  cicatriza- 
tion of  the  involved  lung  tissue,  p/eural  adhesions,  evidences  of  fibro- 
sis, while  the  rest  of  the  lung  may  show  indications  of  emphysema. 
Adventitious  sounds  are  usually,  though  not  invariably,  absent;  the 
case  is  "dry."  Exquisite  amphoric  breath  sounds  may  be  heard  over 
the  site  of  cavities,  combined  with  amphoric  whispered  voice  but  no 
rales.  In  others,  the  site  of  the  lesion  is  only  discovered  by  the  dulness 
on  percussion,  and  feeble  breath  sounds  and  sibilation  are  found  over 
a  circumscribed  area  of  the  chest,  usually  the  upper  part  of  one  side. 
In  many  there  are  found  signs  of  displacement  of  the  mediastinum. 
But  we  have  already  emphasized  the  fact  that  the  physical  signs 
elicited  on  the  chest  are  of  but  little  value  prognostically.  The  writer 
is  under  the  impression  that  a  patient  showing  a  well-defined  line  of 
demarcation  between  the  normal  lung  and  the  affected  part,  has  a 
better  prognosis  than  one  showing  a  gradual  change  from  normal  to 
pathological  lung  tissue.    But  to  this  there  are  many  exceptions. 

The  problems  "Will  the  quiescence  last?"  and  "Is  the  patient  in 
danger  of  a  relapse  of  the  disease?"  can  best  be  .answered  by  a  careful 
consideration  of  the  constitutional  symptom.  In  general  terms  it 
may  be  stated  that  the  patient  is  in  danger  of  two  accidents:  (1) 
pulmonary  hemorrhage;   and  (2)  reactivation  of  the  disease. 

Pulmonary  hemorrhage  cannot  be  foreseen  in  these  cases;  nor  can 
it  be  prevented.  It  may  occur  when  the  patient  is  in  excellent  condi- 
tion. When  not  copious  it  merely  frightens  him,  but  even  brisk  and 
copious  hemorrhages  are  well  borne  by  98  per  cent,  of  patients;  in 
fact  they  feel  better  in  many  cases  after  recovery  from  the  bleeding, 
and  quickly  recuperate.  Some  have  one  such  large  hemorrhage  a  few 
years  after  recovery  from  the  phthisis  and  feel  well  for  many  years 
thereafter  or  even  for  the  rest  of  their  natural  lives.  But  in  about  2  per 
cent,  of  these  bleeders  the  hemorrhages  prove  fatal.  As  was  already 
stated  these  hemorrhages  cannot  be  foreseen  nor  prevented.  Those 
suffering  from  "recurrent  hemoptysis"  hardly  ever  perish  because 
of  the  bleeding.  The  danger  is  a  brisk  hemorrhage  occurring  suddenly 
in  one  who  may  not  have  bled  before. 

The  constitutional  symptoms  are  better  guides  in  prognosis  as  to 
the  chances  of  a  lasting  quiescent  period.  Most  of  these  patients 
with  arrested  phthisis  remain  emaciated,  anemic,  with  wasted  muscles, 
often  presenting  a  cadaverous  appearance.  Despite  this,  many  of 
them  are  very  active  at  their  avocations  and  in  fact  they  display  energy 
and  perseverance  which  is  suprising  when  considered  in  connection 
with  their  physical  decrepitude.  Some  are  rather  well  nourished 
despite^the  fact  that  physical  exploration  shows  a  lesion  of  various 


PROGNOSIS  IN  ARRESTED  DISEASE  437 

degrees  of  activity,  from  cicatrization  to  excavation.  In  my  expe- 
rience, patients  apparently  well  nourished  with  quiescent  or  arrested 
lesions  of  this  class  are  not  as  a  rule  doing  as  well  as  those  of  the  lean 
type,  despite  their  well-nourished  bodies.  We  should  not  allow  our- 
selves to  be  deceived  in  attempting  a  forecast  by  the  amount  of  fat  the 
patient  has,  by  the  fresh  and  browned  skin  which  is  often  merely  a 
superficial  mask  of  improvement  while  the  interior  of  the  organism  is 
vitally  undermined. 

The  prognosis  in  these  two  classes  of  patients  can  only  be  determined 
with  some  degree  of  certainty  by  an  analysis  of  the  following  condi- 
tions :  If  the  improvement  has  been  attained  through  careful  treatment 
in  a  favorable  environment,  the  test  is  whether  the  patient  remains 
in  good  condition  for  some  time  after  returning  to  his  old  environment 
without  suffering  a  relapse  of  the  constitutional  symptoms.  The  test, 
in  other  words,  is  duration;  improvement  counts  if  it  lasts  without 
special  treatment. 

As  long  as  there  is  but  little  cough  or  none  at  all,  no  fever,  no  tachy- 
cardia, dyspnea,  chills,  sweats,  etc.,  the  prognosis  is  good,  no  matter 
what  physical  exploration  discloses.  Continuous  freedom  from  these 
symptoms  for  several  months  is  an  indication  of  arrest,  even  if  tubercle 
bacilli  are  found  in  the  sputum,  while  in  those  in  whom  arrest  has  just 
been  attained,  the  prognosis  is  uncertain  until  time  has  shown  that 
there  is  no  tendency  to  recrudescence.  The  prognosis  is  even  better 
in  those  who,  despite  resumption  of  their  previous  occupation,  or  tak- 
ing up  a  new  one,  and  living  a  rational,  though  not  an  exception- 
ally careful  life,  still  keep  in  good  condition.  On  the  other  hand,  in 
those  who  purchased  quiescence  or  arrest  of  the  disease  by  special 
treatment,  rest,  and  extreme  care,  the  prognoiss  is  less  favorable, 
unless  resumption  of  ordinary  activities  of  life  proves  that  recrudes- 
cence does  not  occur. 

In  short,  the  prognosis  of  quiescent  and  arrested  disease  can  only 
be  made  by  a  careful  observation  for  several  months,  and  noting  the 
effects  of  resumption  of  activities  of  life  on  the  condition  of  the  patient. 


CHAPTER  XXVIII. 
THE  INDICATIONS  FOR  TREATMENT  OF  PHTHISIS. 

The  indications  for  treatment  in  pulmonary  tuberculosis  appear  at 
first  sight  to  be  simple  and  clearly  defined.  On  the  principle  that  the 
first  thing  to  do  is  to  remove  the  cause,  it  would  seem  that  there  are 
but  two  procedures  to  follow:  To  destroy  the  bacilli  which  have 
settled  within  the  body;  or  to  increase  the  resisting  powers  of  the 
patient,  and  thus  render  the  soil  unsuitable  for  the  growth  of  the 
invading  virus.  But  in  this  case  the  ideal,  like  other  ideals,  cannot 
be  achieved  in  the  average  case,  and  the  aim  at  curing  the  patient  by 
the  first  of  these  procedures  is  not  feasible  at  the  present  state  of  our 
knowledge. 

We  have  no  chemical  remedy  which  will  destroy  the  bacilli  harbored 
within  the  body  without  simultaneouslv  killing  the  patient.  We  have 
no  drug  which  will  render  the  tubercle  bacilli  harmless  in  the  body, 
as  quinin  destroys  the  Plasmodium  malarise,  or  salvarsan  and  mercury 
destroy  the  spirocheta  in  syphilis,  leaving  the  patient  in  good  shape. 
Even  the  so-called  specific  treatment — the  various  tuberculins,  sera, 
and  vaccins — which  have  been  lauded  for  their  alleged  curative  powers 
when  properly  administered,  are  not  stated  to  have  any  known  bacter- 
icidal action,  nor  are  they  known  to  hinder  the  proliferation  of  the 
bacilli  within  the  body,  or  to  immunize  the  tissues  against  the  poisons 
engendered  by  these  microorganisms  through  the  production  of  anti- 
bodies, as  is  the  case  with  antitoxins.  Attempts  at  active  immuniza- 
tions have  not  met  with  notable  success  in  tuberculosis. 

The  etiology  of  tuberculosis,  however,  teaches  a  lesson  in  rational 
therapeutics.  The  tubercle  bacilli  do  not  grow  with  equal  facility  in 
every  individual;  if  they  did,  the  number  of  human  beings  who  suc- 
cumb to  this  disease  would  be  equivalent  to  the  number  that  give  posi- 
tive reactions  to  tuberculin,  indicating  that  they  have  been  infected 
with  tubercle  bacilli — over  90  per  cent,  of  the  adult  population  in 
large  urban  centres.  We  have  seen  that  the  bacilli  can  proliferate  and 
produce  their  noxious  effects  only  in  persons  who  offer  a  favorable 
soil  for  their  existence. 

In  what  this  favorable  soil  consists,  we  are  not  altogether  clear. 
In  the  chapter  on  Predisposition  we  discussed  it  in  detail  and  it  was 
evident  that  everything  which  undermines  the  general  health  of  a 
person  and  reduces  his  vitality  may  prepare  a  favorable  soil  for  the 
growth  of  tubercle  bacilli  within  the  body  and  thus  produce  phthisis. 
As  a  corollary  we  may  argue  that  anything  which  will  stimulate  the 
vital  defensive  forces,  which  are  more  or  less  inherent  in  every  indi- 


EPFECTS  OF  POLYMORPHISM  OP  THE  DISEASE  439 

vidual;  or  which  will  improve  the  nutrition  of  the  body,  may  hinder 
the  proliferation  of  the  bacilli,  and  with  the  improvement  in  the  gen- 
eral physical  condition  of  the  patient,  the  local  lesion  may  cicatrize, 
or  the  dissemination  of  the  bacilli  by  metastasis  may  be  prevented. 

This  is  wdiat  modern  phthisiotherapy  is  aiming  at  in  handling  each 
individual  case  of  the  disease.  As  has  been  pointed  out  by  G.  Schroder,^ 
modern  therapeutic  tendencies  which  are  based  on  the  achievements 
of  immunology,  have  not  changed  our  methods  of  treatment  of  tuber- 
culosis, especially  phthisis.  It  is  today,  as  it  was  hitherto,  based  on 
the  general  principles  of  therapeutics,  because  phthisis  cannot  be 
considered  an  infectious  disease  sui  generis.  It  can  only  originate  in 
individuals  with  a  certain  constitutional  susceptibility,  which  may  be 
inherited  or  acquired. 

Air,  Food,  and  Rest. — The  traditional  therapeutic  triad — air,  food, 
rest — has  withstood  the  test  of  time,  and  is  at  present  called  into 
service  more  often  than  ever  before  in  :^he  treatment  of  phthisis. 
Indeed,  like  many  other  excellent  therapeutic  agents  which  have  become 
standard,  it  is  very  often  abused.  Many  patients  know  of  it  and 
quite  often  tell  their  doctor  that  they  are  aware  of  the  fact  that  medi- 
cine is  helpless  and  that  air,  food,  and  rest  is  all  that  they  need. 
Curious  to  say,  some  physicians  do  not  protest. 

But  this  is  all  wrong.  The  medical  man  of  today  has  many  more 
resources  in  his  attempts  at  curing  phthisis,  and  should  not  rely  on 
the  above-mentioned  triad  exclusively.  Indeed,  a  physician  who 
advises  a  patient  to  lead  an  open-air  life  in  some  region  famous  for  its 
beneficial  effects  on  this  disease,  and  urges  him  to  consume  more  and 
better  nourishment  than  he  has  been  in  the  habit  of  taking,  and  to 
stop  all  life  activities,  fulfills  but  part  of  his  duty  to  his  patient.  There 
are  many  more  therapeutic  resources  which  hasten  recovery,  relieve 
the  most  annoying  and  painful  symptoms  of  the  disease,  and  go  a 
long  way  toward  prevention  of  complications,  which  cannot  be  met 
by  the  above-mentioned  indications. 

Effects  of  Polymorphism  of  the  Disease  on  Therapeutic  Indications. 
—Since  the  etiological  unity  of  tuberculosis  has  been  proved  by  the 
discovery  of  the  tubercle  bacillus,  the  profession  has  tacitly  accepted 
that  unity  of  origin  invariably  implies  unity  of  effect,  and  the  treat- 
ment of  the  disease  was  also  unified.  But  this  is  an  error.  We  have 
seen  that  the  tubercle  bacilli  produce  different  lesions  in  different 
individuals,  as  regards  the  anatomical  changes  in  the  lung,  the  clinical 
phenomena  and  the  course  and  curability  of  the  disease.  Indeed, 
there  are  hardly  two  cases  of  phthisis  which  appear  exactly  alike  on 
the  autopsy  table,  and  all  the  groupings  into  caseous,  fibroid,  cavitary, 
pneumonic,  etc.,  are  inadequate.  This  is  especially  true  of  the  clinical 
manifestations  of  the  disease;  its  polymorphism  is  noteworthy  and 
important.     To  be  sure,  this  is  also  true  of  other  diseases,  notably 

1  Handbuch  der  Tuberkulose,  1914,  ii,  1. 


440       THE  INDICATIONS  FOR   TREATMENT  OF  PHTHISIS 

syphilis,  yet  the  specific  remedies  in  the  latter  answer  most  of  the 
indications.  As  long  as  we  are  not  in  possession  of  a  specific  remedy 
for  tuberculosis,  it  will  have  to  be  treated  symptomatically. 

Under  the  circumstances,  to  be  effective,  treatment  must  be  applied 
in  accordance  w^ith  the  clinical  manifestations  encountered  and  to  a 
certain  extent  with  the  clinical  form  of  the  disease.  We  have  seen  that 
each  form  pursues  a  course  more  or  less  different  from  all  other  forms. 
It  would  therefore  be  wrong  to  treat  a  patient  with  abortive  tubercu- 
losis in  the  same  manner,  and  for  the  same  length  of  time  as  one  w^ith 
chronic -progressive  phthisis.  Fibroid  phthisis  demands  different  treat- 
ment than  chronic  caseous  phthisis;  febrile  cases  cannot  be  treated 
like  those  which  run  an  afebrile  course.  The  various  complications 
of  the  disease,  like  intestinal,  laryngeal,  and  renal  tuberculosis  demand 
special  care  which  the  general  indications  do  not  satisfy.  Preexisting 
disease,  like  syphilis,  diabetes,  cardiovascular,  and  renal  derange- 
ments, etc.,  alter  the  course  of  treatment  appreciably.  There  are  also 
differences  in  our  methods  of  treatment  when  w^e  care  for  a  tuberculous 
child  as  compared  with  those  applied  in  adults;  but  in  senile  phthisis 
the  indications  are  not  the  same  as  those  in  adolescents.  The 
indications  are  even  different  in  cases  of  young,  single  women, 
as  compared  with  married  or  pregnant  women,  and  during  the 
menopause  tuberculosis  often  demands  special  treatment. 

It  is  thus  obvious  that  a  method  of  treatment  which  will  suit  all 
cases  cannot  be  formulated.  What  may  be  efficacious  in  one  may  not 
be  feasible  in  another,  or  even  harmful  in  a  third.  The  treatment  of 
phthisis  must  be  individualized  to  suit  the  case,  it  must  be  elastic  and 
adaptable  to  the  polymorphous  nature  of  the  disease  and  to  the  various 
accidents  and  complications  occurring  during  its  course. 

Criteria  of  Efficacy  of  Treatment. — In  judging  the  value  of  any 
method  of  treatment,  we  must  bear  in  mind  some  points  which  are 
usually  neglected  w^hile  speaking  of  this  subject.  The  fact  must  not 
escape  us  that  the  vast  majority  of  cases  of  tuberculosis  manifest  a 
strong  tendency  to  recover  under  any  method  of  treatment,  or  even 
spontaneously.  Impressed  by  the  malignancy  of  the  disease  in  many 
cases,  we  are  apt  to  forget  the  large  number  of  spontaneous  recoveries, 
and  when  we  meet  with  good  results,  we  are  apt  to  attribute  them  to 
the  method  of  treatment  pursued,  forgetting  that  a  large  proportion 
of  patients  would  have  recovered  without  the  treatment. 

Discussing  the  clinical  features  of  abortive  tuberculosis,  we  have 
shown  that  this  form  of  phthisis  is  very  common  and  may  not  be 
recognized.  When  reading  about  a  large  proportion  of  recoveries  in  a 
sanatorium  which  admits  only  "incipient"  cases,  or  of  a  drug  which  is 
alleged  to  cure  at  this  stage  a  certain  proportion  of  cases,  etc.,  we  must 
recall  that  among  these  "early"  cases,  there  is  a  large  nmnber  with 
a  strong  tendency  to  recovery  under  all  circumstances.  To  be  of  real 
value,  a  method  of  treatment  must  be  effective  in  producing  more 
recoveries  than  would  be  ordinarily  anticipated. 


CRITERIA  OF  EFFICACY  OF  TREATMENT'  441 

Even  in  the  forms  of  chronic  phthisis  which  usually  last  for  many 
months  or  years  before  terminating  in  recovery  or  death,  the  course  is 
not  always  progressive,  continuously  advancing.  This  is  evident  from 
the  large  number  of  patients  who  give  a  history  of  hemoptysis,  cough, 
fever,  emaciation,  etc.,  five,  ten,  or  more  years  before  the  onset  of  the 
present  illness,  which  was  diagnosticated  at  the  time  as  tuberculosis, 
but  the  patient  did  well.  For  long  years  he  was  able  to  attend  to  his 
work,  only  being  laid  up  now  and  then  for  a  few  days  with  an  attack 
of  "bronchitis,"  "grippe,"  etc.,  but  this  last  attack  has  proved  persist- 
ent. Now,  if  in  this  case  a  proper  diagnosis  had  been  made  during 
any  of  the  previous  attacks,  the  prompt  recovery  would  have  been 
credited  to  the  special  treatment  applied.  In  fact,  many  patients  tell 
us  that  a  certain  prescription  was  very  effective  for  years  in  relieving 
them  promptly,  but  this  time  it  has  failed. 

All  properly  investigated  statistical  examinations  have  shown  con- 
clusively than  five  3^ears  after  the  onset  of  active  phthisis  about  50 
per  cent,  of  the  patients  are  in  good  or  fair  physical  condition  and 
even  able  to  make  themselves  useful  at  their  respective  occupations, 
irrespective  of  what  method  of  treatment  was  applied.  The  statistics 
of  results  obtained  in  sanatoriums  published  by  Lawrason  Brown, ^ 
Herbert  Maxon  King,^  and  others  show  that  patients  discharged  in 
the  advanced  stages  of  the  disease  are  often  found  alive  and  active, 
five,  ten,  or  even  fifteen  years  later.  A  physician  who  keeps  careful 
records  and  publishes  a  series  of  cases  in  which  such  results  are  shown 
can  impress  the  profession  that  his  method  of  treatment  has  done 
wonders.    Yet,  it  is  just  what  should  be  expected  under  any  method. 

A  study  of  the  literature  on  phthisiotherapy  shows  that  nearly  all 
authors,  urging  their  methods,  report  certain  and  almost  the  same 
percentages  of  patients  "cured,"  "disease  arrested,"  "improved," 
"unimproved,"  and  last,  but  always  least,  "dead."  Practically  all 
sanatoriums,  whether  located  on  high  or  low  altitudes,  at  the  sea- 
coast  or  inland,  in  cold,  warm  or  moderate  climates;  irrespective  of 
the  special  method  of  treatment  pursued — indoors,  outdoors,  or  in 
tents;  no  matter  what  the  fad  or  hobby  of  the  attending  physician,  be 
it  dietetic,  medicinal,  or  specific;  they  all  give  the  same  results  if  we 
should  judge  them  by  the  percentages  of  reported  cures,  improvements 
and  deaths  as  published  in  their  annual  report. 

During  the  first  year  or  two  after  the  introduction  of  new  drugs  or 
specifics,  physicians  report  excellent  results,  as  is  seen  from  the  litera- 
ture on  creosote  and  arsenic  and  their  derivatives,  ichthyol,  cinnamic 
acid,  iodin,  tannin,  succinimide  of  mercury,  etc.  They  all  cured  a 
certain  percentage,  arrested  the  disease  in  a  larger  percentage  and 
failed  only  in  very  acute  or  progressive  or  far-advanced  cases.  Phthis- 
iotherapy has  thus  been  encumbered  with  an  enormous  number  of 
medicaments,  which  have  been  lauded  by  many  competent  and  con- 

1  American  Medicine,  1904,  viii,  879;    Ztschr.  f.  Tuberkulose,  1908,  xii,  206. 

2  National  Assn.  Study  and  Prev.  Tuberc,  1912,  viii,  82. 


442       THE  INDICATIONS  FOR   TREATMENT  OP  PHTHISIS 

scientious  physicians  at  one  time  or  another,  and  condemned  with 
equal  vigor  by  others.  According  to  Renon  the  popularity  of  each  drug 
or  method  of  treatment  hardly  exceeds  three  years. 

These  are  in  fact  the  reasons  why  so  many  new  methods  of  treatment, 
drugs,  specifics,  climates,  diets,  etc.,  are  annually  announced  as  cura- 
tive agents  for  tuberculosis.  They  all  depend  on  the  normal  proportion 
of  recoveries  which  occur  under  any  method.  That  charming  French 
writer,  Louis  Renon,^  says  in  this  connection:  "All  new  therapeutic 
methods  of  treatment  of  tuberculosis,  as  long  as  they  are  harmless, 
always  give  the  same  satisfactory  results.  This  is  an  axiom  which  I 
should  like  to  have  printed  with  heavy  type  in  all  the  new  books  on 
phthisiotherapy.  It  is  an  axiom  which  may  be  clinically  translated 
into  this  simple  statement:  Hurry  and  take  the  treatment  as  long 
as  it  cures;  if  you  wait  you  may  be  too  late." 

The  reasons  for  these  therapeutic  illusions  are  found  in  the  above 
stated  facts.  The  disease  is  acutely  progressive  in  comparatively  few 
cases.  In  these,  all  agree  that  their  remedies  are  of  no  avail,  and  they 
are  not  counted  in  the  reported  cases.  In  a  large  proportion  there  is 
a  strong  tendency  to  spontaneous  cure,  and  they  furnish  the  recoveries 
for  the  special  climates,  specific  and  empiric  therapeutic  agents,  for 
the  "milk  cures,"  the  "song  cure,"  the  "grape  cure,"  etc.  In  the 
majority  of  cases  of  active  phthisis  the  disease  runs  an  undulating 
course,  with  more  or  less  frequent  exacerbations  of  acute  or  subacute 
symptoms,  followed  by  remissions  in  the  activity  of  the  process.  In 
some  the  acute  exacerbations  are  very  infrequent,  long  remissions  are 
obtained,  the  patient  feeling  comparatively  well  for  several  months 
and  the  credit  is  given  to  the  method  of  treatment. 

Psychic  Influences. — Persons  under  the  influence  of  mild  alcoholic 
intoxication  are  very  susceptible  to  suggestion,  and  the  consumptive 
who  is  under  the  influence  of  tuberculous  toxemia  is  very  vulnerable 
to  auto-  and  heterosuggestion,  as  was  shown  in  Chapter  XIII.  Any 
new  drug,  especially  when  boosted  in  the  newspapers,  is  apt  to  relieve 
him  in  a  remarkable  manner.  We  often  meet  with  consumptives  who 
keep  on  sinking  while  under  the  care  of  a  physician,  but  for  some 
reason  are  impelled  to  change  their  medical  adviser  and,  though  the 
latter  makes  no  changes  in  the  treatment,  the  patient  begins  to  gain 
in  health  and  general  well-being.  This  is  usually  the  result  of  a  new, 
careful,  and  minute  physical  examination  by  some  pedantic  physician 
who  subjects  his  patient  to  all  the  diagnostic  procedures — inspection, 
palpation,  percussion  and  auscultation;  "gives  him  the  benefit  of  the 
latest  of  diagnostic  aids,"  the  .T-rays,  the  cutaneous  or  subcutaneous 
tuberculin  test,  examines  the  sputum  and  urine  in  the  presence  of  the 
patient,  etc.,  and  usually  gives  the  same  directions  as  those  of  the 
former  physician,  but  more  minutely;  orders  the  patient  to  report 
frequently  to  see  whether  any  changes  are  necessary.    This  is  often 

1  Le  traitement  pratique  de  la  tuberculose  pulmonaire,  Paris,  1908,  p.  30. 


SUGGESTION  BY  TUBERCULIN  TREATMENT  443 

the  beginning  of  a  most  remarkable  improvement  in  a  case  that  has 
been  going  from  bad  to  worse :  The  appetite  returns,  the  cough  ceases, 
the  nightsweats  disappear,  etc.,  and  they  gain  in  weight  and  strength. 

Suggestion  by  Tuberculin  Treatment. — There  are  many  phthisio- 
therapists  competent  to  give  authoritative  opinion  who  are  convinced 
that  tubercuhn,  as  generally  administered  in  minute  doses,  acts  more  by 
suggestion  than  by  specific  action  on  the  tuberculous  process  in  the 
lung.  We  shall  revert  to  this  subject  while  speaking  of  specific  treat- 
ment. But  meanwhile  we  want  to  point  out  the  powers  of  suggestion 
in  specific  treatment  as  shown  in  a  drastic  manner  by  Albert  Mathieu 
and  Dobrovici,^  who  announced  to  the  tuberculous  patients  at  the 
Andral  Hospital  in  Paris,  that  a  new  discovery  had  been  made,  a 
new  serum  had  arrived  for  the  cure  of  tuberculosis,  and  that  shortly 
a  sufficient  quantity  of  the  remedy  would  be  available  for  those  in  need 
of  it.  The  patients  had  to  wait  for  some  time,  and  when  the  serum 
arrived  they  all  rejoiced.  The  new  remedy  consisted  simply  of  physio- 
logical salt  solution,  but  was  given  the  pompous  name  Antiphymose. 
Certain  patients  were  told  that  they  were  fit  subjects  for  antiphymose, 
while  others  were  denied  the  treatment  on  the  plea  that  it  would  not 
do  them  any  good.  The  selected  patients  were  placed  under  careful 
observation  and  their  histories  were  again  recorded  minutely,  so  that 
all  felt  that  they  had  been  seriously  given  the  first  opportunity  to 
benefit  by  a  great  discovery.  No  change  was  made  in  the  surroundings 
of  the  patient  and  the  diet,  but  all  other  medication  was  discontinued. 

The  patients  were  greatly  impressed  by  the  new  remedy  and  the 
favorable  results  exceeded  all  expectations.  Within  a  couple  of  days 
there  was  noted  an  improvement  in  the  appetite;  those  who  had 
fever  before  showed  a  normal  temperature,  and  the  cough,  expectora- 
tion and  nighsweats  were  ameliorated;  those  who  had  hemorrhages 
ceased  bleeding,  and  even  the  physical  findings  in  the  chest  showed  dis- 
tinct signs  of  amelioration  of  the  process.  The  gain  in  weight  was 
remarkable,  ranging  from  1500  gms;  to  2  and  3  kilos.  As  soon  as  the 
injections  were  discontinued  all  the  old  symptoms  reappeared. 

From  personal  experience'-^  with  the  culture  of  turtle  bacilli  injected 
by  Dr.  F.  F.  Friedmann  into  patients  under  my  care  at  the  Monte- 
fiore  Home  in  New  York  City,  I  can  say  that  its  effects  were  practic- 
ally the  same  as  those  of  Mathieu's  antiphymose.  The  heightened 
susceptibility  to  suggestion  of  the  average  consumptive  were  here 
vividly  illustrated.  No  one  will  deny  that  the  vast  majority  of  people, 
healthy  and  sick,  are  amenable  to  suggestion  in  various  ways,  but  it 
must  be  acknowledged  that  a  group  of  patients  suffering  from  acute 
or  subacute  gout  or  rheumatism,  heart  disease  in  a  state  of  decom- 
pensation, of  nephritis  complicated  by  dyspnea  and  dropsy,  of  ulcer 
of  the  stomach,  of  cancer,  or  of  any  other  organic  pathological  entity, 


1  Bull.  Gen.  de  therapeut.,  1908,  cli,  882. 

2  Fishberg,  Interstate  Med.  Jour.,  1914,  xxi,  349. 


444       THE  INDICATIONS  FOR   TREATMENT  OF  PHTHISIS 

would  not  be  influenced  to  the  same  extent  b}'  suggestion  as  were  the 
consumptives  just  mentioned. 

It  appears  that  consumptives  in  all  stages  of  the  disease  are 
susceptible  to  psychotherapy.  I  have  repeatedly  observed  marked 
improvement  in  the  subjective  s\Tnptoms  of  patients  who  were  told 
by  their  physicians  that  nothing  could  be  done  for  them  because  they 
are  doomed,  while  the  new  physician,  who  was  promptly  called  because 
of  the  extreme  prostration  of  the  patients,  assured  the  unfortunate 
sufferers  that  there  was  no  danger  at  all,  and  that  only  careful  treat- 
ment was  necessary  to  rehabilitate  the  lost  health  and  strength,  and 
afterward  a  short  visit  to  the  country  would  enhance  the  chances  for 
ultimate  recovery.  I  have  seen  improvement  in  a  patient  after  three 
punctures  were  made  in  her  chest  with  a  view  of  inducing  an  artificial 
pneumothorax,  but  no  nitrogen  was  introduced  into  the  pleura  because 
of  adhesions.  Yet  the  temperature  which  had  been  quite  above  nor- 
mal for  weeks  promptly  dropped  to  normal  and  the  patient  felt  well. 
That  tuberculous  patients,  as  a  rule,  improve  during  the  first  few 
weeks  or  months  in  a  new  resort  or  institution  is  a  well-known  fact ;  and 
that  it  is  usually  not  the  superior  climatic  conditions  or  the  different 
method  of  treatment  that  was  efficacious  in  this  respect  is  proved  by 
their  relapse  into  their  former  condition,  or  by  the  aggravation  of  their 
disease  after  the  novelty  of  the  new  surroundings  begins  to  wear  off. 
This  is  the  main  reason  why  climates  "wear  out." 

Psychotherapy  in  Tuberculosis. — This  heightened  susceptibility  of 
the  tuberculous  patients  to  suggestion  is  of  immense  value  and  assist- 
ance to  the  physician  who  is  the  fortunate  possessor  of  a  personality 
which  stands  him  in  good  stead  when  handling  difficult  and  intract- 
able cases.  But  it  is  a  double-edged  sword.  It  also  interferes  in  a 
large  measure  with  the  proper  appreciation  of  the  value  of  any  thera- 
peutic procedure,  because  the  patients  are  apt  to  be  impressed  with 
any  new  remedy,  especially  if  it  has  been  puffed  up  by  an  enthusiastic 
physician,  and  promptly  improve.  But  the  improvement  is  only 
short-lived  and  within  a  short  time  all  the  old  symptoms  return,  as 
we  have  shown. 

This  psychic  trait  of  the  tuberculous  is,  however,  of  immense  value 
in  assisting  all  physicians  in  their  efforts  to  alleviate  the  more  painful 
features  of  the  disease,  provided  they  know  how  to  take  ad^■antage 
of  it.  Indeed,  the  success  of  many  physicians  in  handling  tuberculous 
patients  depends  on  this  point,  and  it  is  a  fact  that  therapeutic  nihilists 
fail,  as  a  rule,  to  give  relief  to  this  class  of  patients.  The  detailed, 
often  written  instructions  given  by  physicians  to  their  patients  in 
sanatoriums,  the  minute  doses  of  tuberculin  administered,  the  vigilant 
anticipation  of  reactions,  and  the  careful  inquiry  as  to  the  effect  on 
the  constitutional  symptoms,  have  all  the  elements  of  suggestive 
therapeutics.  ^Yithout  these  details,  the  institutional  treatment  of 
tuberculosis,  especially  in  private  and  costly  sanatoriums,  would 
be  a  failure. 


THE  INDICATIONS  FOR   TREATMENT  445 

For  these  reasons  the  medicinal  treatment  of  tuberculosis  has  a 
place  in  the  therapeutics  of  tuberculosis.  The  materia  medica  is  of 
assistance  not  only  in  alleviating  certain  annoying  symptoms,  as  we 
will  show  later  on,  but  rational  medication  also  imbues  the  patient 
with  the  idea  that  something  is  being  done  for  him  during  his  long  and 
trying  disease.  ^Medicinal  preparations  are  also  palliative,  to  be  sure, 
but  they  often  carry  the  patient  over  an  acute  crisis  with  more  or 
less  comfort  which  could  not  be  obtained  otherwise,  and  they  stimulate 
a  hopeful  outlook  for  an  ultimate  recovery. 

The  Indications  for  Treatment. — In  the  absence  of  specific  remedies 
the  therapeutic  aims  are  to  increase  the  natural  forces  of  resistance  of 
the  tissues  by  constitutional  treatment  and  by  direct  local  treatment 
of  the  affected  lung.  The  first  indication  is  met  by  certain  general 
therapeutic  measures,  the  second  by  the  induction  of  an  artificial 
pneumothorax.  In  this  book  the  treatment  of  phthisis  is  discussed 
with  a  view  of  methodically  presenting  the  subject  in  the  following 
order : 

1.  General  management  of  the  case. 

2.  Dietetic  management  of  the  case. 

3.  Institutional  treatment. 

4.  Climatic  treatment. 

5.  Medicinal  treatment. 

6.  Specific  treatment. 

7.  Symptomatic  treatment. 

8.  Local  treatment. 

9.  Treatment  of  the  various  forms  of  tuberculosis. 
10.  Treatment  of  the  complications. 


CHAPTER  XXIX. 
PROPHYLAXIS. 

The  recent  discoveries  in  the  field  of  phthisiogenesis  have  shown 
tliat  the  prophylaxis  of  tuberculosis  is  much  more  complex  than  the 
simple  formulae  or  programs  of  antituberculosis  societies  would  indicate. 
A  considerable  part  of  the  sure  preventatives  given  in  popular  and 
technical  literature  have  been  shown  to  be  inefficacious  or  superfluous 
by  the  newer  teachings  of  the  bacteriology,  demography  and  the  clinical 
phenomena  of  this  disease. 

Modern  prophylactic  measures  should  differ  in  accordance  with 
what  we  aim  at  attaining.  If  our  aim  is  to  prevent  infection  with 
tubercle  bacilli,  we  must  take  different  measures  than  those  which  are 
indicated  when  we  aim  at  preventing  phthisis,  the  disease  caused  by 
these  microorganisms.  In  our  attempts  at  preventing  tuberculosis  in 
children  we  must  resort  to  different  prophylactic  methods  than  when 
we  aim  at  preventing  tuberculous  disease  in  adults.  In  fact,  measures 
which  are  likely  to  prove  effective  in  infants  are  not  indicated  in  older 
children,  while  in  adults  most  of  the  measures  which  have  been  fomid 
effective  in  early  life  are  futile,  extravagant  and  even  harmful. 

Prevention  of  Infection. — We  have  seen  that  the  child  is  born  free 
from  tuberculosis,  even  if  its  parents  are  tuberculous  at  the  time  of 
conception  or  birth.  We  have  also  seen  that  during  the  first  year  of 
life  some  become  infected  and  that  the  proportion  showing  signs  of 
harboring  tubercle  bacilli  in  their  bodies  keeps  on  graduall}^  increasing 
with  advancing  years  so  that  at  ten  years  the  vast  majority  are  in- 
fected and  that  at  the  age  of  fourteen  over  90  per  cent,  react  to  tuber- 
culin— an  unmistakable  sign  of  having  been  infected  with  tubercle 
bacilli. 

We  have  also  showai  that  during  the  first  year  of  life  infection,  if  it 
does  occur,  is  likely  to  result  in  an  acute  or  subacute  disease  which 
proves  fatal  in  nearly  all  cases.  On  the  other  hand,  after  passing  the 
age  of  infancy  infection  becomes  less  dangerous,  only  rarely  causing 
death,  though  it  is  liable,  when  localizing  itself  in  glands,  bones  and 
joints,  to  cause  prolonged  sickness  and  end  in  disfigurement,  if  the 
patient  survives. 

Our  main  aim  is  therefore  clear.  The  infant  under  two  years  of  age 
must  be  protected  against  tuberculous  infection  at  all  costs.  In 
families  in  which  there  is  no  tuberculous  member  this  is  a  simple 
matter.  Impressing  the  parents  that  infants  acquire  tuberculosis 
very  readily,  as  easily  as  measles,  scarlet  fever,  influenza,  etc.,  and 
that  a  single  exposure  is  liable  to  result  in  infection,  they  can,  with 
reasonable  and  ordinary  care,  shelter  their  young  offspring  against 


PREVENTION  OF  INFECTION  447 

the  tubercle  bacilli.  Especially  is  this  an  easy  matter  with  mothers 
who  suckle  their  babies,  and  do  not  give  them  any  cow's  milk,  so  that 
bovine  infection  is  entirely  excluded. 

An  infant  is  naturally  not  apt  to  come  in  contact  with  strangers 
unless  those  who  care  for  it  bring  it  in  their  proximity.  Realizing  that 
there  are  so  many  persons  with  open  tuberculosis  who  are  considered 
quite  healthy,  or  who  consider  themselves  healthy,  it  is  obvious  that 
in  order  to  positively  avoid  infection  at  that  age,  infants  must  not  be 
brought  in  contact  with  any  one  excepting  the  immediate  family  who 
are  known  to  be  free  from  the  disease. 

But  it  must  be  remembered  that  the  immediate  family  includes  the 
grandparents,  and  they  are  often  suffering  from  latent  tuberculosis. 
The  impression  is  gaining  ground  of  late  that  a  large  proportion  of  the 
chronic  bronchitis,  pulmonary  emphysema,  asthma,  etc.,  in  aged 
persons,  is  of  a  tuberculous  character,  as  was  already  shown  in  the 
chapter  on  phthisis  in  the  aged.  The  writer  in  attempting  to  trace 
the  source  of  infection  has  often  found  that  it  was  the  coughing  or 
expectorating  grandfather  or  grandmother  who  was  responsible  for 
the  disease  in  an  infant. 

Great  care  is  to  be  exercised  in  selecting  domestic  servants  for  homes 
with  infants.  Especial  care  is  to  be  taken  with  the  nurse  for  an  infant. 
She  should  be  carefully  examined  by  a  physician,  and  reexamined  if 
she  acquires  a  "cold"  that  lasts  more  than  a  week. 

These  simple  measures  suffice  in  homes  in  which  there  are  no 
tuberculous  inhabitants.  No  infant  should  be  allowed  to  remain  in  a 
home  in  which  a  phthisical  person  resides.  Even  if  the  patient  is  one  of 
the  most  scrupulous  and  takes  excellent  care  of  his  sputum,  he  should 
not  live  in  the  same  home  in  which  an  infant  is  raised.  This  is  a  point 
which,  in  our  efforts  to  prevent  the  dissemination  of  the  disease,  is 
often  overlooked.  Following  up  phthisical  patients,  the  authorities 
usually  state  that  a  careful  consumptive  is  harmless,  as  long  as  he 
takes  care  of  his  expectoration,  and  permit  tuberculous  persons  to 
live  in  the  same  home  with  infants.  But  as  a  matter  of  fact  the  harm- 
lessness  of  consumptives  extends  only  to  adults,  and  not  because  they 
are  taking  extreme  care  of  their  expectoration,  but  for  other  reasons 
which  will  be  given  later  on  in  this  chapter.  As  regards  infants,  no 
care,  however  conscientiously  exercised,  can  surely  prevent  infection. 
And  infection  in  infants  is  likely  to  prove  deadly. 

The  indications  are  therefore  clear.  Either  the  phthisical  person 
or  the  infant  is  to  be  removed.  No  compromise  can  be  allowed  in 
such  cases. 

No  tuberculous  mother  is  to  be  allowed  to  rear  her  young  children, 
especially  during  infancy.  It  has  been  found  that  very  few  infants 
survive  when  suckled  by  a  mother  suffering  from  phthisis.  The 
extensive  statistics  of  Weinberg,^  embracing  5000  families  with  18,000 

1  Die  Kinder  der  Tuberkulosen,  Leipsic,  1913. 


448  PROPHYLAXIS 

children,  have  shown  that  the  nearer  the  birth  of  the  children  to  the 
time  of  death  of  their  tuberculous  parents,  the  higher  the  mortality 
among  them.  Three-fourths  of  the  children  born  during  the  last 
year  of  life  of  the  tuberculous  mothers,  succumb;  and  90  per  cent, 
of  the  children  born  during  the  last  month  of  life  of  tuberculous 
mothers  die.  The  investigations  of  the  present  writer^  among  children 
of  tuberculous  parentage  in  New  York  City  have  shown  practically 
the  same  condition  to  prevail.  In  addition  to  the  excessive  mortality 
in  general,  16  per  cent,  of  the  deaths  among  children  under  six  years 
of  age  were  due  to  tuberculous  meningitis,  as  against  only  1 .27  per  cent, 
among  the  general  population  of  New  York  City, 

The  prophylactic  value  of  separation  of  the  infant  from  its  tuber- 
culous parents  is  well  exemplified  by  experiences  with  tuberculous 
animals.  Harlow  Brooks^  shows  that  among  cattle  the  question  of 
whether  or  not  the  offspring  becomes  tuberculous  depends  entirely 
upon  exposure  after  birth.  It  has  been  conclusively  shown  that  the 
calves  are  very  rarely,  if  ever,  infected  before  birth,  but  that  the 
slightest  carelessness  in  exposure  of  the  newborn  calves  to  infections 
leads  to  certain  disaster.  It  has  been  found  that  tuberculous  animals 
may  be  utilized  for  breeding  purposes  and  that  they  may  be  crossed 
and  inbred  with  entire  disregard  of  the  factor  of  tuberculosis  and 
purely  for  the  purpose  of  improving  or  maintaining  the  type,  provided 
the  calves  are  separated  from  the  parents  immediately  after  birth. 

Similar  measures  have  to  be  taken  in  cases  of  newborn  infants  of 
tuberculous  parentage.  If  the  mother  is  tuberculous  the  infant  is 
to  be  removed  immediately  after  delivery,  and  should  not  be  allowed 
in  her  proximity  during  the  first  two  years  of  life.  If  the  father  is 
phthisical,  he  should  be  removed  from  the  home,  as  long  as  there 
are  infants  under  two  years  of  age.  In  some  cases  the  alternative  of 
removing  the  infant  may  be  more  feasible.  Bernheim  induced  three 
tuberculous  mothers  who  had  twins  to  separate  with  one  child  each, 
while  retaining  the  others  in  their  homes,  though  healthy  wet-nurses 
were  employed  to  suckle  the  babies.  The  three  isolated  children 
remained  healthy,  while  the  three  which  were  raised  at  home  suc- 
cumbed to  tuberculosis. 

It  is  noteworthy  that  improvement  in  the  sanitary  and  hygienic 
conditions,  which  are  so  effective  in  preventing  phthisis  in  the  adult, 
as  will  be  shown  later  on,  are  not  of  any  value  in  the  case  of  infants. 
As  has  been  pointed  out  by  Romer,  it  was  found  that  scrupulous  atten- 
tion to  hygiene  and  sanitation  of  the  stable,  such  as  proper  construc- 
tion, ventilation,  cleanliness,  etc.,  hardly  has  any  influence  on  the 
prevalence  of  tuberculosis  in  cattle  and  that  only  strict  isolation  of 
the  sick  from  the  healthy  animals  is  effective.  Primary  infection  in 
infants  appears  to  follow  the  same  law:  Exposure  of  an  infant,  even 
in  an  ideal  home,  may  result  in  fatal  tuberculosis,  while  life  under 

'  Archives  of  Pediatrics,  1914,  xxxi,  96,  197. 
-  Amer.  Jour.  Med.  Sci.,  1914,  cxlviii,  718. 


PROPHYLAXIS  IN  CHILDREN  OVER  THREE  YEARS  OF  AGE     449 

adverse  conditions  will  not  produce  tuberculous  disease,  unless  there 
is  a  source  of  infection,  which  is  usually  the  human  consumptive 
and  rarely  the  milk  derived  from  tuberculous  cow^s.  In  the  devel- 
opment of  phthisis  in  adults  hygienic  and  sanitary  conditions  play, 
however,  a  very  important  role. 

The  prevention  of  bovine  tuberculosis  is  not  to  be  neglected.  When 
an  infant  must  be  hand  fed,  the  milk  should  be  carefully  selected.  In 
large  cities  the  only  drawback  is  the  cost.  Certified  milk  is  every- 
where available,  but  it  is  rather  expensive  and  prohibitive  for  the  vast 
majority  of  the  population.  For  this  reason  all  milk  that  is  not  derived 
from  a  source  known  to  be  safe,  is  to  be  pasteurized  or  better  yet, 
sterilized. 

These  simple  measures  are  to  be  taken  with  a  view  of  successfully 
preventing  primary  infection  of  infants  under  three  years  of  age. 
They  can  be  easily  carried  out  by  any  family  which  has  some  degree 
of  economic  independence.  In  families  which  are  to  some  extent 
hampered  because  of  economic  stress,  the  State  is  to  interfere.  Health 
Boards,  which  are  busy  protecting  adults  against  infection  to  which 
they  are  hardly  susceptible,  could  perform  really  useful  service  if  they 
concentrated  more  and  more  along  these  lines.  The  mortality  during 
the  tender  age  of  infancy,  which  has  hardly  been  influenced  by  the 
campaign  against  tuberculosis,  would  be  reduced  to  a  minimum. 
Moreover,  massive  infection,  which  is  apparently  responsible  for 
phthisis  in  the  adults  who  have  survived  it  during  infancy,  may  thus 
be  largely  prevented. 

Prophylaxis  in  Children  over  Three  Years  of  Age. — When  the  child 
begins  to  walk  around  and  comes  in  contact  with  many  people,  pre- 
vention of  infection  is  not  simple.  The  parents,  especially  those  who 
cannot  afford  a  maid  for  each  child — and  they  constitute  the  bulk  of 
population — lose  control  over  their  children,  unless  they  are  prepared 
to  keep  them  altogether  from  contact  with  strangers  and  this  is  not 
feasible  for  obvious  reasons.  Later  when  they  go  to  school,  they  are 
bound  to  come  in  contact  with  other  children  and  adults  and  it  is 
altogether  impossible  to  prevent  their  meeting  tuberculous  individuals, 
no  matter  what  the  economic  condition  of  the  parents.  It  is  thus  clear 
that  it  is  altogether  impossible  to  prevent  tuberculous  infection  among 
children  over  four  or  five  years  of  age. 

But,  as  was  shown  in  Chapter  XXIV,  infection  in  children  over  four 
years  of  age  is  usually  relatively  harmless.  Either  no  disease  at  all 
occurs,  or  rarely,  tracheobronchial  adenopathy  results,  which  is  serious 
only  on  exceedingly  rare  occasions. 

Available  evidence  tends  to  show  that  in  infants  infection  is  usually 
accomplished  within  the  family — tuberculosis  is  exceedingly  rare  in 
infants  who  live  in  homes  in  which  there  is  no  phthisical  member. 
When  this  is  the  case,  we  may  trace  the  infection  to  someone  living 
in  the  house  as  a  lodger,  or  to  some  relative  or  friend  who  visits  the 
home  and  comes  in  intimate  contact  with  the  infant,  thus  causing 
29 


450  PROPHYLAXIS 

massive-  infection.  With  children  of  play  and  school  age,  the  oppor- 
tunities for  intimate  contact  with  adult  strangers  are  scarce;  they  are 
not  taken  in  the  arms,  not  kissed  indiscriminately,  etc.,  and  even 
when  infection  takes  place  it  is  from  another  child,  a  playmate,  etc., 
is  slight,  and  not  as  massive  as  it  is  apt  to  be  in  infants,  who  are 
infected  from  adults. 

There  is  abundant  clinical  evidence  of  the  relative  harmlessness  of 
infection  of  children  over  four  years  of  age.  One  has  but  to  consult 
the  mortality  returns  in  any  country  to  convince  himself  that  between 
three  and  fifteen  years  of  age  the  mortality  rates  from  tuberculosis 
are  comparatively  low,  despite  the  fact  that  over  90  per  cent,  of  the 
tuberculous  infection  of  humanity  takes  place  during  this  period  of 
life.  Comparing  the  results  of  infection  during  the  first  two  years  of 
life,  and  those  taking  place  between  four  and  fifteen  years  of  age,  the 
contrast  is  striking  and  convincing  (see  p.  359).  Neither  acute  tuber- 
culosis nor  chronic  phthisis  of  the  adult  is  common  in  children  of  school 
age.  Thus,  among  925,000  children  examined  by  the  medical  school 
inspectors  in  New  York  City  during  the  school  year  September,  1914 
to  June,  1915,  only  68  were  found  tuberculous.^  When  we  bear  in 
mind  that  each  was  examined  by  physicians  and  nurses  once  in  six 
weeks  on  the  average,  and  that  a  complete  physical  examination  was 
made  of  all  children  three  times  during  the  course  of  the  elementary 
school  year,  and  that  a  cough  noted  by  the  teacher  was  sufficient  to 
refer  the  child  for  examination,  it  is  obvious  that  not  many  suffering 
from  tuberculosis  were  overlooked. 

Under  the  circumstances,  we  may  conclude  that  no  matter  what 
the  cause  is,  infection  of  children  during  school  age  is  comparatively 
harmless,  and  that  inasmuch  as  experience  has  taught  that  everybody 
is  bound  to  be  infected  with  tubercle  bacilli,  the  best  that  can  happen 
is  that  infection  should  occur  at  the  age  period  of  four  to  fourteen  years. 
The  primary  mild  infection  at  that  age,  as  we  have  shown  above, 
practically  vaccinates  humanity  against  more  severe  infections  in  later 
years.  Otherwise,  all  adults  would  be  as  susceptible  to  tuberculosis 
as  are  guinea-pigs,  or  the  indigenous  races  of  Central  Africa. 

Our  efforts  are  therefore  to  be  directed,  next  to  the  prevention  of 
of  contact  of  infants  with  tuberculous  persons,  at  the  prevention  of 
massive  infection  of  children.  This  can  be  done  within  certain  limits 
by  preventing  children  from  associating  with  individuals  suffering 
from  open  tuberculosis.  The  danger  lurks  mostly  in  adults,  because 
children  expectorating  tubercle  bacilli  are  exceedingly  rare. 

Prevention  of  Reinfection.^ — It  thus  appears  that  the  bacilli  infecting 
children  remain  dormant  within  the  body,  and  cause  no  disease,  as 
long  as  there  are  no  predisposing  or  exciting  causes.  We  know  that 
under  certain  circumstances  these  dormant  bacilli  activate  and  cause 
disease  by  metastatic  auto-infection.    This  is  mainly  seen  in  cases  in 

1  Weekly  Bulletin  of  the  Department  of  Health,  City  of  New  York,  1915,  iv,  289. 


PROPHYLAXIS  IN  ADULTS  451 

which,  owing  to  defective  nutrition,  or  some  intercurrent  disease, 
notably  measles,  whooping  cough,  typhoid,  etc.,  the  resistance  is 
reduced,  and  an  exacerbation  of  the  tuberculous  process  takes  place. 
Moreover,  it  appears  that  the  younger  the  child,  the  more  is  the  anergy 
thus  induced  likely  to  be  followed  by  active  tuberculous  disease.  The 
indications  are  therefore  clear — young  children  and  infants  are  to  be 
sheltered  against  the  endemic  diseases.  Special  care  is  to  be  exercised 
in  this  direction  with  children  of  tuberculous  parentage,  who  have  in 
all  probabilities  suffered  from  massive  infection.  This  class  of  infants 
is  to  be  scrupulously  shielded  against  measles,  whooping-cough,  scarlet 
fever,  diphtheria,  etc.  If  these  diseases  are  bound  to  attack  them,  it 
is  best  that  it  should  occur  after  they  have  passed  the  fourth  year 
of  life. 

During  convalescence  after  one  of  these  endemic  diseases,  the  child 
is  to  be  given  special  care,  with  a  view  of  preventing  metastatic  auto- 
infection  while  the  body  is  in  a  state  of  anergy;  in  other  words,  sus- 
ceptible. This  may  be  done  by  either  taking  the  child  to  the  country, 
preferably  to  the  seashore,  for  a  few  weeks  or  months,  till  it  has  com- 
pletely recuperated;  or  when  it  must  be  kept  at  home  it  should  be 
given  proper  nourishment,  and  kept  outdoors  the  greater  part  of  the 
day,  and  it  should  sleep  in  a  room  with  open  windows. 

Prophylaxis  in  Adults. — Prophylaxis  in  adults  is  no  more  a  problem 
of  infection.  It  may  be  taken  for  granted  that  everyone  who  has  passed 
through  the  first  fifteen  years  of  life,  especially  in  a  city,  has  been 
infected  with  tubercle  bacilli.  The  fact  that  he  shows  no  symptoms 
and  signs  of  disease  is  no  proof  that  he  has  escaped  infection,  as  was 
already  shown.  In  adults,  the  problem  is  the  prevention  of  disease, 
of  phthisis.  I  believe  that  a  considerable  portion  of  the  inefficacy  of 
the  campaign  against  tuberculosis  is  due  to  the  lack  of  appreciation 
of  this  distinction  between  infection  and  disease. 

This  fact  is  based  on  the  newer  investigations  in  phthisiogenesis, 
which  have  conclusively  proved  two  points: 

1.  That  chronic  phthisis  in  the  adult,  of  the  type  that  creates  most 
of  the  tuberculosis  problem,  never  occurs  immediately  after  a  primary 
infection;  if  disease  occurs  at  all  soon  after  a  primary  infection,  it  is 
of  the  acute  types  of  tuberculosis  of  the  lungs  or  of  other  organs. 
Indeed  when  disease  follows  immediately  after  a  primary  infection  of 
an  adult  it  is  almost  invariably  deadly,  as  is  seen  in  tuberculosis 
of  primitive  peoples  who  have  not  been  exposed  to  infection  during 
childhood. 

2.  Infection  with  tubercle  bacilli,  whether  it  causes  disease  or 
not,  renders  the  body  immune  against  further  and  renewed  exogenic 
infection  with  the  same  virus.  Inasmuch  as  nearly  all  adults  have 
been  infected  with  tubercle  bacilli  during  their  childhood,  they  are 
immune  against  reinfection  with  bacilli  which  may  be  eliminated 
by  tuberculous  persons.  The  phthisical  manifestations  in  adults  are 
attributed  to  the  infection  during  childhood,  just  as  the  tertiary  mani- 


452  PROPHYLAXIS 

festations  of  syphilis  are  late  results  of  the  original  infection  years 
ago,  though  the  body  is  immune  against  renewed  exogenic  infection 
with  the  same  virus. 

If  this  w^as  not  a  fact,  practically  all  the  workers  in  hospitals  for 
consumptives  would  succumb  to  the  disease ;  all  consorts  of  tuberculous 
persons  would  acquire  the  disease.  One  has  to  consider  that  of  women 
married  to,  and  living  with,  husbands  suffering  from  active  syphilis, 
hardly  any  escape  infection.  But  we  see  thousands  of  tuberculous 
persons  living  with  consorts,  having  children  with  them,  yet  the 
unaffected  consorts  remain  in  good  health,  as  we  have  already  shown 
in  detail  (see  p.  110). 

It  is  therefore  a  vain  effort  to  follow  up  tuberculous  persons,  push 
them  from  pillar  to  post,  interfere  with  their  employment,  as  has  been 
done  in  many  cases  with  a  view  of  preventing  infection  of  fellow-work- 
men. If  these  individuals  cannot  infect  their  husbands  or  wives,  as 
the  case  may  be,  despite  the  intimate  contact,  they  are  surely  not  a 
menace  to  their  fellow- workmen. 

This  fact  is  now  beginning  to  be  recognized  by  those  who  are  well- 
informed  about  the  recent  progress  in  our  knowledge  of  phthisiogenesis. 
There  has  been  manifesting  itself  a  reaction  against  the  absurd  and 
cruel  phthisiophobia  which  has  been  rampant  for  about  twenty-five 
years.  Baldwini  says:  "Adults  are  very  little  endangered  by  close 
contact  with  open  tuberculosis,  and  not  at  all  in  ordinary  association. 
.  .  .  It  is  time  for  a  reaction  against  the  extreme  ideas  of  infec- 
tion now  prevailing.  There  has  been  too  much  read  into  the  popular 
literature  by  health  boards  and  lectures  that  has  no  sound  basis  in 
facts  and  it  needs  to  be  dropped  out  and  revised." 

Prevention  of  Phthisis. — It  appears  that  in  the  eager  chase  after  the 
bacteria,  which  could  never  be  entirely  destroyed,  we  have  forgotten 
that  only  a  small  portion  of  those  infected  develop  phthisis,  while 
the  rest  are  apparently  benefited  by  the  infection.  Some  recent 
^^Titers  have  not  hesitated  to  apply  the  term  benevolent  infection  to 
those  who  have  been  fortunate  in  acquiring  tuberculosis  during  later 
childhood  and  have  thus  been  immunized  against  primary  infection 
after  fifteen  years  of  age,  when  the  disease  produced  by  a  primary 
infection  is  apt  to  run  an  acute  and  fatal  course.  Otherwise,  we 
would  all  succumb  to  the  acute  and  fatal  forms  of  tuberculosis. 

Phthisis  is  a  disease  occurring  in  persons  who  have  been  infected 
with  tubercle  bacilli  many  years  before  the  outbreak  of  the  disease. 
It  is  due  to  reinfection.  But  available  evidence  appears  to  point  in 
the  direction  that  the  reinfection  occiirs  from  within,  that  it  is  metas- 
tatic ;  the  bacteria  which  have  remained,  dormant  for  years  are  slowly 
or  suddenly  reawakened  into  activity  and  they  produce  new  lesions; 
and  that  exogenic  reinfection  is  exceedingly  rare,  if  at  all  possible. 

We  know  that  certain  conditions  favor  a  reduction  in  the  normal 

1  Johns  Hopkius  Hosp.  Bull.,  1913,  xxiv,  220. 


PHTHISIOPHOBIA  453 

resisting  powers  of  the  body  and  permit  the  proliferation  of  the  dor- 
mant bacilh.  Among  these,  inferior  sanitary,  hygienic,  and  economic 
conditions  stand  out  preeminently.  We  have  seen  that  the  rates  of 
wages,  the  number  of  rooms  in  which  a  family  lives,  the  character 
of  the  work  pursued  by  an  individual,  etc.,  have  a  strong  influence  in 
the  direction  of  enhancing  or  preventing  the  evolution  of  phthisis.  For 
this  reason,  the  philanthropic  agencies  may  do  more  toward  the 
prevention  of  phthisis  by  concentrating  their  attention  on  improve- 
ments along  economic  lines  of  reform  than  by  sending  agents  to  tell 
adults  that  it  is  dangerous  to  remain  in  the  proximity  of  a  consump- 
tive. Labor  unions  do  better  by  exacting  higher  wages  and  shorter 
hours  than  driving  unfortunate  phthisical  persons  from  their  places  of 
employment,  as  is  being  done  of  late  in  New  York  City. 

Phthisiophobia. — Phthisis  is  undoubtedly  an  exacerbation  of  dor- 
mant tuberculous  processes  in  the  lungs;  its  entire  clinical  course  is 
undulating,  with  periods  of  quiescence  interrupted  by  periods  of 
activity.  These  acute  and  subacute  exacerbations  may  be  prevented 
by  careful  attention  to  the  general  health  of  any  individual  who  shows 
the  least  tendency  to  phthisical  disease.  Such  individuals  should  not 
be  hounded,  refused  employment,  etc.  They  are  to  be  helped  along  in 
the  direction  of  securing  easy  work  during  the  quiescent  periods,  so 
that  they  may  be  self-supporting  and  self-respecting.  The  words  of 
an  intelligent  and  observing  consumptive  on  this  subject  are  to  be 
borne  in  mind  by  social  workers,  who  of  late  seem  to  know  more  of  the 
etiology  and  prevention  of  tuberculosis  than  those  who  have  made  a 
special  study  of  the  subject.  Says  the  American  historian,  William 
Garrot  Brown,  in  his  Confessions  of  a  Cotisumptice: 

"The  public  depends  for  protection  from  such  danger  as  our  con- 
tinued existence  involves,  not  on  its  own  exertions  but  on  ours.  To 
render  that  protection  we  must  burden  ourselves  with  both  expense 
and  trouble.  We  must  incessantly  take,  for  the  sake  of  the  public, 
precautions  which  are  disagreeable  and  costly;  and  meanwhile  a  great 
part  of  the  public  is,  by  its  attitude  toward  us,  steadily  tempting  us, 
and  even  sometimes  fairly  compelling  us,  if  we  would  live  to  discon- 
tinue these  precautions  and  go  on  as  if  there  were  nothing  the  matter 
with  us.  The  folly  and  stupidity  of  this  attitude  it  is  impossible  to 
overstate.  It  is  of  itself  by  far  the  chief  cause  and  source  of  the 
persistence  of  this  scourge. 

"  Known  and  recognized  and  decently  entreated,  we  are  not  danger- 
ous. Shunned  and  proscribed  and  forced  to  concealments  we  are 
dangerous.  Victims  ourselves  of  this  same  regime  of  ignorant  and  self- 
deceiving  inhumanity,  we  are  called  on  every  hour  of  our  lives  for  a 
magnanimous  consideration  of  others.  Society  can  hardly  find  it 
surprising  or  a  grievance  if  our  human  nature  should  sometimes  weaken 
under  the  strain  of  the  incessant  provocation  it  endures  from  this 
strange  working  of  human  nature  in  general.  Why  should  we  alone 
be  expected  to  be  guiltless,  always  to  our  own  cost  and  sacrifice,  of 


454  PROPHYLAXIS 

that  very  form  of  man's  inhumanity  to  man,  from  which  we  ourselves 
are  suffering  more  than  anybody  else?  Yet  I  can  honestly  attest  that 
the  vast  majority  of  us  are  guiltless  of  any  merely  resentful  offense; 
that,  as  a  rule,  when  we  fail  to  protect  the  public  it  is  only  because  the 
public  compels  us  to  disregard  its  interest,  its  safety.  This  is  what  I 
earnestly  entreat  the  public,  for  its  o\sti  sake,  candidly  to  consider. 

"Candidly  means  fully.  If  the  public  is  to  be  safe  from  us,  if  the 
public  is  to  continue  to  have  our  protection  from  that  against  which  it 
failed  to  protect  us,  then  the  public  must  make  it  possible  for  us  to  get 
• — it  must  certainly  cease  to  make  it  impossible  for  the  mass  of  us  to 
get  anything  except  by  subterfuge — what  we  must  have  to  live.  We 
are  neither  criminals  nor  mendicants.  We  do  not  ask  favors,  we 
merely  revolt  against  a  mean  and  stupid  oppression.  We  revolt  against 
ignorance  and  against  a  lie.  The  public  would  get  rid  of  us,  and  thereby 
makes  us  inescapable.  It  would  pretend,  and  would  have  us  pretend, 
that  we  are  nowhere.  It  thereby  insures  that  we  shall  be  everj^'here. 
It  proscribes  us  and  thereby  admits  us." 

If  the  average  consumptive  was  not  shunned  by  adults;  if  he  was 
permitted  to  work  unmolested  after  he  is  cured  or  the  disease  is  arrested, 
or  quiescent,  allowing  him  to  earn  his  livelihood,  a  considerable  part  of 
the  economic  stress  caused  by  this  disease  would  be  done  away  with. 
If  the  tuberculous  individual  is  told  that  he  is  only  a  menace  to  infants, 
less  dangerous  to  children,  and  not  at  aU  dangerous  to  adults,  he  will 
surely  take  all  precautions  against  infecting  those  who  may  be  harmed 

But  at  present  the  State,  municipal,  philanthropic  and  social  agencies 
that  send  out  representatives  telling  those  who  live  with  consumptives 
that  the  patients  must  be  shunned,  and  incidentally  conveying  the 
information  that  a  careful  patient,  i.  e.,  one  who  takes  care  of  his 
sputum,  is  not  at  all  dangerous  even  to  infants.  Some  patients  in  New 
York  City  are  actually  dreading  lest  their  names  will  be  reported 
to  the  authorities,  and  they  will  be  pestered  by  those  well-meaning 
nurses,  physicians,  social  w^orkers,  etc.  Instead  of  telling  the  patient 
that  he  is  only  a  menace  to  infants,  and  that  he  must  keep  away  from 
them,  they  often  visit  his  place  of  emplo}Tnent  and  the  result  is  that 
the  unfortunate  patient  is  soon  without  a  job  and  starving. 

The  results  of  these  methods  of  phthisiophobia  are  seen  in  the 
fact  that  the  number  of  infants  which  succumb  to  tuberculosis  has 
not  decreased  even  in  Germany  where  antituberculosis  agencies  have 
been  most  active;  that  the  number  of  persons  infected  with  tubercle 
bacilli  has  not  decreased  is  clear  when  we  consider  that  over  90  per  cent, 
of  humanity  react  to  tuberculin. 

I  do  not  want  to  be  understood  as  speaking  unfavorably  of  all  prophyl- 
actic measures  against  tuberculous  infection  of  adults.  There  are  many 
especially  among  the  richer  classes  in  cities,  and  in  suburban  and  rural 
districts,  who  have  escaped  infection  during  childhood,  and  they  should 
be  protected.  It  is  in  fact  well  known  that  tuberculosis,  when  occrn'ring 


DISPOSAL  OF   THE  SPUTUM  455 

in  these  classes  is  often  of  an  acute  type,  just  as  it  is  in  the  indigenous 
races  of  Central  Africa,  or  the  Esquimaux.  They  should  be  protected 
against  the  sputum  indiscriminately  expectorated  by  consumptives, 
and  against  droplet  infection  when  coming  in  contact  with  persons 
suffering  from  active  phthisis.  But  with  the  city-bred  people,  espe- 
cially those  who  have  survived  in  the  congested  parts  of  cities,  or  the 
slums,  there  is  hardly  any  danger  that  adults  will  be  infected  with 
tubercle  bacilli.  They  have  been  infected  during  childhood;  vacci- 
nated and  immunized  against  additional  infection.  But  it  is  just  among 
these  that  the  strong  efforts  are  made  to  prevent  exposure  of  adults 
to  infection.  The  irony  is  that  their  infants  are  usually  neglected  by 
the  social  forces  working  in  the  antituberculosis  campaign. 

Just  as  the  cattle  breeders  have  found  that  the  control  of  tuberculosis 
is  mainly  a  matter  of  prevention  of  infection  of  newborn  calves,  and 
that  adult  cattle  may  be  disregarded,  so  must  we  act  with  humans. 
To  prevent  infection,  newborn  infants  must  be  protected  while  children 
over  ten  and  adults  need  no  special  measures,  especially  those  who  have 
been  raised  in  cities. 

Disposal  of  the  Sputum. — ^In  our  attempts  at  preventing  infection, 
the  disposal  of  the  sputum  expectorated  by  phthisical  patients  is  more 
important  than  any  other  prophylactic  measure.  The  saprophytic 
bacilli  are  distributed  in  virulent  form  only  from  one  animal  body  to 
another.  Exceptionally,  the  source  of  the  bacilli  is  a  domestic  animal, 
mainly  milk  from  tuberculous  cows,  but  in  the  vast  majority  of 
cases  the  source  of  infection  is  sputum  expectorated  by  phthisical 
patients. 

For  this  reason  the  rigorous  laws  prohibiting  indiscriminate  expec- 
toration which  enlightened  communities  have  inaugurated  are  fully 
justified,  and  they  ought  to  be  more  rigorously  enforced.  It  should  be 
made  clear  that  tuberculosis  is  not  the  only  disease  which  is  transmitted 
by  expectoration,  but  many  other  diseases  are  dangerous  in  this  regard, 
so  that  nobody  ought  to  spit  on  the  floor  of  a  house  or  public  place. 
Furthermore,  there  are  many  tubercle  bacillus  "carriers"  who  do  not 
suffer  from  the  disease  which  they  are  liable  to  transmit,  especially  to 
infants  and  children.  The  fact  that  indiscriminate  expectoration  is 
enforced  irrespective  of  the  question  whether  the  offender  is  tuber- 
culous or  not,  makes  it  easier  to  exact  it  from  the  phthisical  patients, 
who  do  not  like  to  be  stigmatized. 

In  the  case  of  children,  especially  infants,  it  is  not  only  sputum  which 
is  dangerous,  but  also  the  droplets  flying  out  of  the  mouth  and  nose 
during  the  acts  of  coughing,  sneezing,  and  talking.  For  this  reason  a 
consumptive  should  not  associate  with  infants,  even  if  he  is  careful 
with  his  expectoration.  Droplet  infection  may  prove  disastrous  to 
infants.  In  the  case  of  adults,  coughing  and  sneezing  are  hardly  dan- 
gerous. We  have  already  mentioned  Saugman's  conclusion  that  it 
is  not  dangerous  for  adults  to  be  coughed  at  by  a  tuberculous  patient 
(seep.  110). 


456  PROPHYLAXIS 

Cuspidors. — The  disposal  of  the  expectoration  is  therefore  an 
important  problem,  and  it  has  been  suggested  that  the  best  means  of 
rendering  it  harmless  is  that  it  should  invariably  be  deposited  in  some 
form  of  cuspidor. 

Floor  cuspidors  in  rooms,  especially  in  public  places,  are  a  nuisance; 
they  cannot  be  tolerated  in  any  decent  home  for  both  sanitary  and 
esthetic  reasons.  They  are  unsightly,  and  just  as  much  of  the  sputum 
is  often  deposited  around  the  vessel  as  within  it.  Flies,  cats,  and  dogs 
are  frequent  visitors  and  with  mouths  or  legs  covered  with  sputum  may 
proceed  further  in  their  quest  for  food,  and  deposit  the  bacilli  on  food 
which  is  subsequently  used  by  the  inhabitants  of  the  house.  The 
elevated  cuspidors,  of  which  we  find  such  beautiful  illustrations  in  a 
certain  variety  of  books  on  tuberculosis,  may  be  good  for  certain 
institutions,  especially  those  harboring  advanced  consumptives,  but 
they  should  not  be,  and  are  not,  used  in  homes  and  public  buildings. 
They  are  also  an  invitation  to  spit;  they  provoke  expectoration  in 
persons  who  otherwise  would  not  do  it.  This  is  the  reason  why  they 
are  hardly  seen  anywhere,  except  in  institutions. 

The  pocket  sputum  flasks  are  objectionable  for  other  reasons.  Their 
variety  is  great,  if  we  are  to  judge  by  the  large  number  illustrated  in 
popular  books  on  the  prevention  of  tuberculosis.  The  ingenuity  of 
the  designers  or  inventors  is  noteworthy  and  could  have  been  used  to 
better  advantage  in  other  directions.  They  are,  however,  not  used 
outside  of  institutions  to  any  noticeable  extent.  I  fancy  that  a 
person  who  would  take  out  a  sputum  flask,  even  one  of  those  which 
look  like  cigar  boxes,  lunch  boxes,  etc.,  and  spit  into  it  within  the 
sight  of  people  in  a  public  place,  would  create  a  miniature  panic 
among  some  who  have  read  popular  literature  on  the  prevention  of 
tuberculosis. 

They  are  objectionable  for  another  reason.  No  matter  how  wide- 
necked  they  are  made,  the  patient  must  apply  his  lips  to  the  mouth 
of  the  flask  if  he  wants  to  deposit  the  sputum  within  it.  The  result 
is  that  part  of  the  sputum  sticks  to  the  lips  or  mustache  and  beard,  and 
this  must  be  removed  with  a  handkerchief.  Even  if  all  male  patients 
would  consent  to  shave  clean  it  would  not  help.  I  have  observed  that 
the  lips  are  very  often  covered  with  sputum  after  the  patient  has 
expectorated  into  any  of  these  flasks. 

In  institutions  they  should  be  used,  and  the  ones  made  of  pasteboard, 
kept  in  a  tin  frame-holder,  are  the  best.  Patients  in  the  advanced 
stages  of  the  disease  should  use  them  at  home  in  case  they  expectorate 
large  quantities  of  sputum. 

But  I  can  see  no  reason  for  urging  them  on  patients  in  the  incipient 
stages  of  the  disease,  expectorating  but  little  sputum.  Physicians 
trying  to  imitate  legislators  who  pass  laws  which  they  know  cannot 
be  enforced,  defeat  their  own  ends.  We  cannot  induce  a  patient  to 
carry  a  sputum  flask  with  him,  no  matter  how  fine  and  deceptive  its 
construction  may  be,  and  to  use  it  in  public.    I  have  also  known  some 


DUTIES  OF  COMMUNITY  IN  PREVENTION  OF  PHTHISIS    457 

patients  in  the  incipient  stages  of  the  disease  who  left  sanatorinms 
because  they  could  not  tolerate  their  fellow-sufferers  walking  around 
with  sputum  cups  in  their  hands.  Advanced  patients  are  hardened 
in  this  respect  as  a  rule. 

Patients  in  the  incipient,  or  quiescent,  stages  of  the  disease  can 
empty  their  chests  in  the  morning  into  cuspidors  containing  some  cheap 
disinfectant.  It  should  soon  be  emptied  into  the  water-closet.  Urging 
them  to  burn  it  is  usually  a  vain  effort,  if  only  because  there  are 
no  facilities  in  modern  homes  for  the  purpose.  Those  expectorating 
considerable  quantities  may  efficiently  dispose  of  their  sputum  by  the 
use  of  paper  napkins,  as  suggested  by  Landis.^  Toilet  paper  will  also 
answer  the  purpose.  Several  thicknesses  are  folded  once,  so  as  to 
receive  the  sputum;  the  paper  is  again  folded  and  the  ends  folded 
over  so  as  to  enclose  the  expectorated  material,  and  then  placed  in  a 
grocer's  bag  (about  6  by  12  inches).  The  bag  can  be  pinned  to  the  side 
of  the  bed  or  clamped  to  the  small  bed  table.  Several  times  a  day, 
depending  on  the  amount  of  sputum,  the  bag  and  its  contents  should 
be  burned,  if  there  are  facilities  for  the  purpose.  The  folded  paper 
pockets  containing  the  sputum  may,  however,  be  disposed  of  by 
dropping  them  singly  into  the  water-closet  and  flushing  it  immediately. 

There  is  no  question  that  there  are  valid  objections  to  the  handker- 
chief, though  it  is  not  as  strong  a  menace  as  some  writers  would  lead  us 
to  believe.  But  the  average  patient  will  use  nothing  else  for  reasons 
already  stated.  Portable  sputum  cups  are  used  only  in  institutions 
and  in  homes,  but,  despite  the  agitation  in  their  favor,  we  fail  to 
meet  persons  in  the  streets  or  public  places  of  any  large  city  in  the 
world  carrying  and  expectorating  into  them,  although  we  know  that 
thousands  of  consumptives  are  everywhere.  Even  if  it  is  a  compromise, 
we  must  submit  to  the  inevitable  and  permit  patients  to  use  handker- 
chiefs. It  is  best  that  they  should  be  made  of  gauze  or  cheap  cotton 
which  may  be  destroyed  after  use;  or  they  may  be  of  Japan  paper 
which  may  be  deposited  into  the  water-closet  which  is  immediately 
flushed.  If  made  of  better  material,  the  handkerchief  should  be  boiled 
before  washing.  Boiling  is  a  better  and  surer  bactericide,  especially 
of  tubercle  bacilli  in  sputum,  than  any  chemical  disinfectant. 

Duties  of  the  Community  in  the  Prevention  of  Phthisis. — In  its 
demands  on  the  consumptive  to  shape  his  life  in  such  a  manner  as  to 
prevent  the  dissemination  of  the  disease,  the  community  must  not 
neglect  its  own  duties  to  the  unfortunate  individual,  who  is  suffering 
to  a  great  extent  because  of  conditions  which  the  authorities  have 
permitted  to  prevail.  The  community  must  not  only  provide  shelter, 
proper  nourishment  and  medical  attendance  for  those  patients  who  are 
not  in  a  position  to  procure  it  at  their  own  expense,  but  must  also  see 
to  it  that  the  conditions  favoring  the  development  of  phthisis  should 
be  eliminated. 

1  Hare's  Modern  Treatment,  Philadelphia,  1910,  i,  740. 


458  PROPHYLAXIS 

Laws  regulating  the  sanitary  and  hygienic  conditions  of  dwellings 
for  the  working  people,  among  whom  the  proportion  of  phthisical 
patients  is  highest,  should  be  passed  and  rigorously  enforced.  Tenement 
house  laws,  passed  and  enforced,  have  a  greater  influence  on  the  reduc- 
tion of  the  morbidity  and  mortality  from  consumption  than  all  the 
lectures  delivered  in  and  out  of  season  to  social  workers,  policemen, 
teachers,  and  workmen,  on  the  perils  of  the  tubercle  bacilli  and  the 
best  means  of  killing  them.  The  demolition  of  the  old-style  tenements 
with  numerous  rooms  without  windows,  has  saved  many  more  per- 
sons from  developing  phthisis  than  all  the  sanatoriums  which  are 
supposed  to  isolate  the  sources  of  infection,  but  which,  in  fact,  exclude 
those  in  the  advanced  stages  and  permit  them  to  come  into  intimate 
contact  wdth  infants  and  children.  The  abolition  of  the  sweat-shops 
in  New  York  City  deserves  more  credit  for  the  prevention  of  phthisis 
than  all  the  leaflets  which  have  been  distributed  by  so  many  over- 
lapping agencies,  each  eager  to  get  at  the  persons  who  cough  as  a 
result  of  tuberculosis  or  some  other  disease  and  "follow  them  up." 

Light  and  well-ventilated  dwellings  and  workshops  are  of  prime 
importance  in  preventing  phthisis,  and  the  community  in  which  there 
are  no  rooms  without  windows  and  no  sweat-shops  or  factories  which 
are  dark  and  badly  ventilated  has  the  least  consumptives  to  care  for. 

Good  wages  and  short  hours,  allowing  good  nourishment  and  time 
for  outdoor  exercises  and  recreation  are  important  in  the  control  of 
phthisis. 

Marriage  of  the  Tuberculous. — The  problem  of  marriage  is  one 
which  the  physician  often  has  to  solve  for  his  patients.  We  frequently 
have  to  answer  the  question  whether  a  non-phthisical  consort  should 
continue  to  live  with  the  phthisical  partner;  or  whether  a  tuberculous 
patient,  in  any  stage  of  the  disease,  may  enter  the  married  state. 
Answering  these  questions  involves  a  consideration  of  several  factors. 
The  dangers  of  transmission  of  the  disease  to  the  non-phthisical  con- 
sort; the  dangers  to  the  potential  ofl^spring;  and  the  efl^ect  of  the 
married  state  on  the  patient. 

The  dangers  of  transmission  of  the  disease  to  the  consort  are  negli- 
gible. We  have  seen  that  statistics  prove  that  the  unaffected  consorts 
of  consumptives  are  no  more  liable  to  become  phthisical  than  others 
of  the  same  age  and  social  condition  (see  p.  110).  The  unaffected  con- 
sort has  undoubtedly  been  infected  during  childhood,  and  reinfection 
is  not  likely.  Whether  he  or  she  will  develop  phthisis  depends  on 
factors  other  than  reinfection  from  the  patient.  The  conclusion  is 
therefore  justified  that  as  regards  transmission  of  the  disease  alone 
there  is  no  more  danger  in  marriage  of  phthisical  patients  than  in  cases 
of  cancerous  or  diabetic  patients.  Our  answer  is  to  be  about  the 
same  as  when  two  persons  who  had  both  been  previously  infected 
with  syphilis  ask  whether  they  are  permitted  to  marry. 

The  danger  to  the  children  that  may  result  from  the  union  is 
enormous.     If  the  newborn  child  will  remain  in  the  proximity  of  the 


MARRIAGE  OF  THE  TUBERCULOUS  459 

phthisical  parent,  it  will  most  likely  become  infected  during  infancy 
and  succumb.  Under  the  circumstances,  unless  they  are  satisfied  to 
remove  the  child  immediately  after  birth  and  not  see  it  till  it  has  passed 
the  first  two  years  of  life,  phthisical  patients  should  not  procreate. 
This  is  a  point  which  cannot  be  emphasized  too  strongly  to  tuberculous 
patients  who  are  married  or  contemplate  marriage.  It  is  especially 
dangerous  for  an  actively  phthisical  woman  to  raise  infants.  They 
will,  we  can  say  almost  without  exception,  acquire  the  disease  and 
succumb  during  the  first  year  of  life. 

The  effects  of  the  married  state  on  the  patient  is  different  in  men  as 
compared  with  women.  On  the  average  male  patient  in  the  incipient 
or  moderately  advanced  stages  of  the  disease,  sexual  intercourse  has 
the  same  effect  as  on  the  average  person  who  is  not  in  perfect  health. 
If  he  indulges  moderately  it  does  him  no  harm  at  all;  in  fact,  it  may 
be  beneficial  because  it  prevents  brooding  over  enforced  abstinence 
which  is  often  seen  among  all  classes  of  men.  It  also  precludes 
venereal  complications  which  may  have  an  effect  on  the  phthisical 
process. 

With  women  things  are  different.  As  long  as  they  do  not  become 
pregnant  there  are  no  strong  and  valid  reasons  against  married  life. 
In  fact,  among  the  working  classes  the  married  consumptive  woman 
is  better  situated  than  the  single  who  soon  after  becoming  tuberculous 
also  becomes  a  dependent;  and  if  she  has  no  family  to  care  for  her, 
is  doomed.  But  pregnancy,  childbirth,  and  lactation  are  functions 
which  are  of  grave  augury  for  a  consumptive  woman.  Occasion- 
ally we  see  that  during  the  pregnant  state  the  tuberculous  process  in 
the  lung  improves,  and  the  general  condition  of  the  patient  is  strikingly 
ameliorated.  But  in  the  vast  majority  of  cases,  soon  after  childbirth 
there  is  an  acute  or  subacute  exacerbation  of  the  disease  and  the 
patient  succumbs  within  a  few  months. 

Married  tuberculous  women  are  therefore  to  be  given  detailed 
instruction  on  the  proper  methods  of  prevention  of  conception.  If 
they  become  pregnant  the  induction  of  abortion  is  indicated  and  justi- 
fied both  for  the  sake  of  the  prospective  child,  which  is  bound  to 
become  tuberculous  unless  removed  from  the  proximity  of  the  mother 
immediately  after  birth,  and  for  the  sake  of  the  mother,  who  is  liable 
to  succumb  to  acute  or  subacute  tuberculosis  soon  after  childbirth. 

The  demands  made  by  some  enthusiastic  advocates  of  eugenics  that 
tuberculous  persons  should  be  prohibited  by  law  from  marrying,  has 
no  scientific  basis  in  view  of  what  has  been  stated  above.  The  race 
is  not  in  danger  of  deterioration  because  of  children  derived  from 
tuberculous  stock.  We  have  already  mentioned  that  tuberculous 
cattle  have  been  used  for  breeding  purposes  by  removing  the  calves 
immediately  after  birth.  We  see  no  reason  why  this  should  not  hold 
in  human  beings.  Moreover,  prohibition  of  legal  marriage  does  not 
exclude  extramarital  sexual  intercourse  and  childbirth  with  their 
concomitants.      Free  instruction  on  the  means  of  prevention  of  con- 


460  PROPHYLAXIS 

ception  is  more  likely  to  eliminate  phthisical  stock  and  thus  prove  of 
eugenic  value,  than  prohibition  of  marriage. 

A  patient  presenting  himself  or  herself  with  the  problem  of  mar- 
riage should  be  explained  the  situation  along  the  lines  just  detailed 
and  if  he  or  she  is  intelligent,  we  may  rest  assured  that  the  action  will 
be  reasonable  for  both  the  married  couple  and  the  community.  The 
ignorant  and  reckless  will  not  consult  us  in  such  matters  and  if  they 
do,  they  will  not  follow  instructions.  For  this  reason,  they  should  be 
left  out  of  consideration  in  discussions  of  this  kind.  One  thing  I  always 
insist  on  with  my  patients :  The  unaffected  partner  must  be  informed 
about  the  true  state  of  affairs  and  given  the  choice.  Very  often  it 
will  be  found  that  a  good  woman  will  greatly  help  along  a  consump- 
tive toward  a  recovery  which  could  not  have  been  attained  if  the 
patient  had  remained  single;  or  that  a  female  patient  will  recover  after 
marriage  to  a  man  who  gives  her  a  good  home,  proper  food,  etc. 


CHAPTER  XXX. 
GENERAL  MANAGEMENT  OF  THE  CASE. 

Should  the  Patient  be  Told  that  He  is  Tuberculous? — ^The  diagnosis 
of  pulmonary  tuberculosis  having  been  definitely  made,  there  arises 
the  question  whether  the  patient  should  be  told  the  true  nature  of 
his  disease.  Many  physicians  are  inclined  to  keep  him  in  ignorance 
as  to  the  true  state  of  affairs,  and  to  tell  him  that  he  is  merely  affected 
with  a  "mild  bronchial  catarrh,"  "pleurisy,"  "a  protracted  cold," 
etc.  Very  often  a  patient  is  brought  to  the  office  by  relatives  and 
friends  who  beg  the  physician  that  in  case  tuberculosis  is  diagnosti- 
cated, the  patient  should  under  no  circumstances  be  told  the  truth. 

There  are  many  valid  reasons  against  such  a  procedure.  From  the 
standpoint  of  the  physician's  personal  interests,  it  is  bad  practice.  It 
is  always  to  be  borne  in  mind  that  the  patient  will  sooner  or  later 
find  out  the  truth  and  blame  his  doctor  for  deception  or,  more  often, 
accuse  him  of  ignorance  and  claim,  with  considerable  justice,  that  had 
he  been  informed  in  time  he  might  have  taken  better  care  of  himself. 

But  there  are  reasons  of  more  importance  than  the  doctor's  interests 
for  telling  the  truth  to  every  patient  on  such  occasion.  It  must  never 
be  lost  sight  of  that  tuberculosis  is  transmissible,  particularly  to 
infants  and  children,  and  that  the  patient  must  be  warned  against 
the  possibility  of  disseminating  the  seeds  of  the  disease.  This  can 
only  be  done  by  telling  the  patient  the  true  state  of  affairs  and  giving 
him  details  of  the  principles  of  prevention.  Moreover,  the  average 
patient  knows  that,  in  many  cases,  the  chances  of  recovery  diminish 
with  the  advance  of  the  disease,  and  negligence  in  informing  him  of 
his  opportunities  at  the  earliest  possible  time  may  prove  disastrous. 
We  do  not  know  of  any  quick  cures,  and  the  cooperation  of  the  patient 
is  absolutely  essential.  He  can  only  take  proper  care  of  himself  and 
those  around  him  when  he  knows  the  true  situation. 

It  is  noteworthy  that  relatives  and  friends  who  have  requested  a 
physician  to  keep  the  patient  in  ignorance  of  the  fact  that  he  is  tuber- 
culous are  always  grateful  in  the  end  when  he  is  tactfully  informed  of 
the  truth. 

Irrespective  of  requests  of  friends  and  relatives  the  patient  is  to 
be  told  plainly  and  unequivocally  that  he  suffers  from  tuberculosis. 
In  really  incipient  cases  this  can  be  done  in  several  instalments  because 
it  usually  requires  several  examinations  to  make  a  positive  diagnosis. 
But  when  finally  told,  it  is  to  be  emphasized  that  he  is  in  the  incipient 
and  curable  stage,  and  assurances  given  that  in  his  case  the  prognosis 


462  GENERAL  MANAGEMENT  OF  THE  CASE 

is  very  favorable.  But  it  must  be  insisted  upon  that  the  patient's 
cooperation  is  absolutely  essential  to  attain  a  cure.  An  intelligent 
patient  may  be  given  details  of  the  nature  of  the  disease  and  it  may 
be  pointed  out  that  his  ovv^n  determination  to  follow  instructions  is  of 
more  importance  than  all  the  medicines  and  climates;  in  fact  with- 
out his  own  cooperation,  he  is  lost  even  if  he  consults  the  best  known 
specialists,  enters  the  most  famous  sanatorium,  or  emigrates  to  any 
climatic  resort.  It  is  a  striking  fact  that  nervous  and  excitable  patients 
who  are  expected  by  their  relatives  to  break  down  on  hearing  the 
truth,  resign  themselves  to  their  fate  and  often  display  a  courage  and 
determination  worthy  of  heroes. 

"Unless  we  carry  conviction  to  our  patients,"  says  Arthur  Latham,'^ 
"they  are  unlikely  to  put  up  with  the  restrictions  which  are  inevitable 
to  proper  treatment.  It  is  a  disastrous  thing  to  talk  about  a  "weak 
spot"  in  the  lung.  It  is  our  duty,  in  an  overwhelming  proportion  of 
cases,  to  state  his  position  frankly  to  the  patient,  to  explain  intel- 
ligibly the  reasons  for  the  treatment  prescribed,  and  the  possible  pen- 
alties which  may  have  to  be  faced  if  our  advice  is  neglected.  If  we 
can  convince  our  patient,  we  shall  in  all  probability  have  won  his 
loyal  cooperation,  which  is  half  the  battle:  if  we  fail  to  convince  him 
or  get  him  to  see  the  reasonableness  of  our  advice,  we  cannot  expect  to 
find  treatment  carried  out  with  sufficient  earnestness  and  consistence 
to  be  of  real  value." 

The  suggestion  has  been  made  by  Penzoldt^  that  the  dose  of  truth 
given  to  the  patient  should  be  in  inverse  ratio  to  the  seriousness  of 
the  case — ^the  less  the  chances  of  recovery,  the  smaller  the  dose  of 
truth.  In  incipient  and  hopeful  cases  the  whole  truth  is  best,  but 
the  term  "consumption"  should  be  avoided  in  all  cases;  "tuberculosis" 
is  a  term  which  covers  everything  for  the  patient,  though  as  we  have 
seen,  it  is  not  exactly  correct  scientifically  or  clinically.  But  in  the 
popular  mind  it  has  been  of  late  considered  a  hopeful  and  curable 
disease,  if  taken  in  time.  Some  patients  may  be  told  that  when 
neglected  "tuberculosis"  may  turn  into  consumption. 

As  Abraham  Jacobi^  well  says:  "When  a  patient  strikes  a  doctor 
who  recognizes  a  human  being  in  the  forlorn  creature  before  him  he 
is  told  that  he  has  tuberculosis.  When  he  addresses  a  young  colleague, 
an  immature  colleague,  a  colleague  satisfied  with  and  gratified  by  the 
possession  of  a  diploma  and  who  likes  to  exhibit  his  knowledge  and 
authority,  he  is  told  he  has  "consumption."  "You  have  tuberculosis. 
If  it  were  to  get  worse  it  would  run  into  consumption.  But  cases 
of  tuberculosis  may  and  often  do  get  well,  so  there  is  no  reason  for 
despair." 

It  is  different  with  advanced  and  hopeless  cases.  They  present 
themselves  asking  whether  their  cough  is  really  due  to  consumption 

1  Practitioner,  1913,  xc,  38. 

2  Handbuch  der  Therapie,  1910,  iii,  205. 
'  American  Medicine,  1905,  x,  1063, 


RELATION  OF  PHYSICIAN   TO  PATIENT  463 

and  it  is  at  times  a  pity  to  tell  the  unfortunate  patients  the  true  state 
of  affairs;  not  unless  we  are  not  averse  to  shortening  their  days.  Still, 
for  obvious  reasons  it  is  always  imperative  that  some  relative  or 
friend  should  be  told  the  truth.  Similarly,  in  cases  of  acute  or 
subacute  pulmonary  tuberculosis,  or  in  progressive  cases  with  com- 
plications, such  as  those  suffering  from  diabetes,  tuberculosis  of 
the  kidneys,  etc.,  in  addition  to  the  active  pulmonary  lesion,  it  is 
often  advisable  to  console  the  unfortunate  and  doomed  patient  if  he 
likes  it,  by  telling  him  that  the  prognosis  is  excellent. 

Economic  and  Social  Conditions. — In  outlining  the  treatment  to  be 
pursued,  the  social  and  economic  condition  of  the  patient  is  always 
to  be  borne  in  mind.  It  is  not  advisable  to  tell  a  patient  of  limited 
means  that  a  certain  private  sanatorium,  or  a  climatic  resort  in  a 
distant  part  of  the  country,  is  good  for  him.  He  is  likely  to  brood  over 
the  fact  that  owing  to  his  poverty  he  is  lost,  when  in  fact  he  could 
get  along  very  well  at  home  or  in  the  neighborhood  of  his  city.  Well- 
to-do  patients  may  be  sent  out  of  town  with  only  suspicious  symptoms 
and  signs  of  the  disease  on  the  principle  of  some  physicians  to  treat  all 
"suspects"  as  tuberculous  until  proved  to  be  free  of  the  disease.  The 
rest  during  the  vacation  does  them  good;  in  fact,  they  usually  need 
it.  But  the  patients  with  limited  means  should  never  be  treated  in 
this  manner.  In  them  only  a  positive  diagnosis  of  tuberculosis  should 
be  the  criterion  for  radical  treatment. 

Relation  of  Physician  to  Patient. — A  great  deal  has  been  written 
about  the  relation  of  the  physician  and  his  tuberculous  patient  and  it 
has  been  repeatedly  stated  that  the  former  must  possess  certain 
qualifications  which,  if  taken  seriously,  would  exclude  99  per  cent, 
of  practitioners  from  the  category  of  physicians  competent  to  handle 
an  ordinary  case.  According  to  one  writer,  the  physician  must  pos- 
sess no  less  than  an  extraordinarily  strong  personality,  immense  will- 
power to  impress  it  on  his  patients,  unusual  teaching  ability,  fervent 
enthusiasm  and  unremitting  interest,  etc.,  if  he  is  to  meet  with  success. 

Evidently  these  requirements  are  such  as  all  ideal  physicians  should 
possess  if  they  are  to  be  fit  for  successful  practice.  The  truth  is  that 
in  most  cases  it  is  quite  easy  to  gain  the  confidence  and  cooperation 
of  the  patient,  if  this  is  at  all  obtainable.  The  main  problem  is  to 
retain  it  for  the  long  period  of  time  it  takes  until  the  termination  of 
the  case.  This  is  especially  true  of  chronic  phthisis  which  runs  an 
undulating  course  with  accidents  (hemorrhages,  fever,  anorexia,  etc.) 
which  come  and  go  unexpectedly  and  are  liable  to  shatter  the  most 
implicit  confidence.  This  is  one  of  the  reasons  why  tuberculous 
patients,  next  to  those  suffering  from  venereal  diseases,  are  the  best 
prey  for  quacks  and  charlatans. 

My  observations  lead  me  to  the  conviction  that  the  average  tuber- 
culous patient  can  be  easily  managed  and  his  confidence  retained  for 
an  indefinite  time  when  we  appeal  to  his  reason.  It  is  a  grave  mistake 
of  many  superintendents  of  public  sanatoriums  who  try  to  obtain  the 


464  GENERAL  MANAGEMENT  OF   THE  CASE 

cooperation  of  their  patients  by  keeping  them  in  constant  fear  of 
punishment — expulsion.  As  one  patient  told  me,  the  superintendent 
inflicted  severe  punishment  on  patients  for  small  infractions  of  the 
rules  of  the  institution  because  for  these  dependent  patients  the  only 
hope  of  recovery  was  the  sanatorium.  Such  severity  does  not  at  all 
help  along  in  gaining  the  coniidence  of  patients.  I  know  of  public 
sanatoriums  in  which  the  patients  are  always  coerced  into  obedience  of 
the  rules  and  to  submitting  to  prescribed  treatment,  but  they  do  not 
discharge  the  proper  proportion  of  cured  patients  and  a  very  large 
number  leave  the  institutions  of  their  own  volition  before  the  physi- 
cians discharge  them. 

To  a  certain  extent  the  patient  treated  by  his  physician  at  home 
is  more  amenable  to  reason  than  those  in  public  sanatoriums.  The 
physician  in  private  practice  is  in  a  position  to  individualize  his  cases 
and  more  easily  persuade  them  that  their  only  chances  for  recovery 
lay  in  their  implicit  obedience  of  orders.  When  the  patient  is  told 
the  reason  why  we  want  him  to  rest  the  greater  part  of  the  day  for 
weeks  or  months ;  why  we  want  him  to  eat  certain  kinds  and  quanti- 
ties of  food ;  why  we  want  him  to  submit  to  the  operation  for  artificial 
pneumothorax,  etc.,  he  is  more  likely  to  submit  than  when  we  threaten 
him.  All  this  can  be  done  with  alleged  ignorant  patients,  who  usually 
have  more  common  sense  than  they  are  credited  with,  as  well  as  with 
the  intelligent  and  cultured.  In  fact,  the  former  are,  as  a  rule,  more 
tractable  than  the  latter.  We  must  always  remember  that  these 
patients  make  great  sacrifices  for  months,  and  need  consolation  and 
encouragement  which  only  the  reasonable  physician  is  able  to  bestow. 

Personal  Hygiene. — The  first  instructions  given  to  the  patient  are 
as  regards  his  personal  hygiene.  This  can  best  be  done  only  after 
careful  inquiry  into  his  daily  habits  which,  as  a  rule,  are  found  not 
to  have  been  exemplary;  otherwise  he  would  not  have  been  likely 
to  develop  phthisis.  To  be  successful,  it  is  necessary  to  enter  into 
the  smallest  details  of  every-day  life  and  most  patients  appreciate 
it  greatly. 

Treating  patients  in  cities,  after  deciding  against  a  sanatorium,  it 
is  of  immense  importance  to  ascertain  their  home  surroundings.  ^  A 
call  should  be  made  on  the  house  of  the  patient  to  see  whether  it  is 
fit  for  a  tuberculous  individual,  and  especial  attention  should  be  paid 
to  the  location  of  the  sleeping  room,  its  size,  windows,  exposure,  etc. 
In  case  these  are  not  found  satisfactory,  moving  should  be  urged, 
preferably  to  the  outskirts  of  the  city  or  a  suburb.  Details  are  given 
in  Chapter  XXXII. 

In  our  attempts  at  adapting  the  patient's  mode  of  life  to  the  thera- 
peutic indications,  we  meet  with  great  obstacles  when  trying  to  im- 
press him  with  the  urgency  of  cessation  of  work,  physical  and  mental, 
and  it  is  particularly  difficult  to  pursuade  patients  with  mild  lesions 
showing  few  constitutional  symptoms.  They  are  convinced  that  work 
does  them  no  harm.     The  poor  point  to  the  necessity  for  providing 


PERSONAL  HYGIENE  465 

for  themselves  and  those  dependent  on  them,  while  the  well-to-do 
are  apt  to  be  even  more  intractable  in  this  regard.  They  must  not 
neglect  their  business,  they  must  finish  some  task  they  have  under- 
taken, they  are  deeply  absorbed  in  some  studies;  they  must  continue 
at  college  until  graduation,  etc.  But  the  careful  physician  is  not 
moved  by  these  pleas  and  points  out  to  the  patient  that  just  because 
he  is  in  such  good  physical  condition  the  prognosis  is  so  good.  But 
should  he  continue  working  physically  or  mentally,  the  disease  will 
surely  make  inroads  on  his  vitality  and  the  chances  of  ultimate  and 
complete  recovery  will  vanish.  Whether  he  "leaves"  the  city  or  not, 
the  patient  may  be  induced  to  take  a  complete  vacation  with  all  the 
separation  from  the  activities  of  life  a  vacation  entails,  but  without 
any  of  its  pleasures.  The  details  about  rest  and  exercise  are  given  in 
Chapter  XXXI. 

Baths. — The  mortal  fear  for  "colds"  entertained  by  many  is  accen- 
tuated as  soon  as  the  diagnosis  of  tuberculosis  is  made  and  one  of  the 
first  results  is  that  the  patient  ceases  to  bathe.  In  many  advanced 
cases,  or  even  in  incipients  who  suffer  from  profuse  nightsweats,  large 
patches  of  pityriasis  versicolor  are  to  be  seen  on  the  skin  of  the  neck 
and  trunk.  When  told  that  bathing  will  remove  it,  women  are  easily 
induced  to  take  frequent  baths.  But  all  are  to  be  explained  that 
bathing  improves  the  circulation,  activates  the  skin  and  invigorates 
the  individual.  It  must  be  insisted  upon  that  the  patient  bathes 
frequently  and  follows  it  up  by  vigorous  rubbing  of  the  skin  with  a 
rough  towel. 

The  question  of  cold  baths  in  tuberculosis  has  been  very  much 
debated.  In  some  institutions,  cold  baths  and  frictions  are  the  chief 
elements  of  the  cure.  They  are  urged  for  the  purpose  of  hardening 
the  body  against  colds.  But  many  are  not  fit  for  the  purpose  of 
hardening ;  they  do  not  react  properly  and,  instead  of  feeling  refreshed 
and  invigorated  after  a  cold  bath,  their  extremities  are  livid,  benumbed, 
chilled,  and  they  feel  altogether  miserable.  These  patients,  indepen- 
dent of  their  physical  condition,  are  better  off  when  taking  only  warm 
baths  twice  or  thrice  weekly  followed  by  frictions.  The  statements 
of  some  that  every  tuberculous  patient  can  be  subjected  to  a  process 
of  hardening,  if  methodically  applied,  does  not  hold  as  is  evident 
from  the  fact  that  it  is  not  pursued  systematically  in  most  sanatoriums. 
S.  A.  Knopfs  is  "convinced  that  in  phthisical  patients  the  routine 
application  of  cold  water  in  the  form  of  douch  or  rain  bath  can  be 
productive  of  a  great  deal  of  harm."  Bed-ridden  patients  may  be 
sponged  with  tepid  or  even  cold  water  during  febrile  attacks  with 
great  benefit.  Patients  who  have  been  in  the  habit  of  taking  cold 
baths,  douches  or  sponging  every  morning  should  continue  to  do  so 
during  their  illness,  but  those  who  do  not  bear  these  procedures  well 
should  only  bathe  in  warm  water,  as  was  just  stated. 

1  Medical  Record,  1915,  Ixxxviii,  173. 
30 


466  GENERAL  MANAGEMENT  OF   THE  CASE 

Robust  patients  may  also  be  allowed  swimming  within  reasonable 
limits;  bathing  outdoors,  especially  sea  bathing,  is  good  for  quiescent 
cases.  Turkish  and  Russian  baths  are  decidedly  harmful  in  active 
cases. 

Clothing. — The  tuberculous  patient  should  be  sensibly  clothed;  the 
aim  being  to  keep  him  warm  during  the  cold  winter,  but  not  over- 
heated. The  fear  for  "colds"  is  responsible  for  the  excessive  under- 
wear which  we  often  find  on  patients,  and  coupled  with  the  several 
vests,  sweaters,  coats,  and  overcoats,  they  are  often  fairly  borne  down 
by  the  weight  of  their  clothing.  The  well-known  red  flannel  pad,  "the 
chest  protector,"  has  not  has  yet  been  abandoned  after  all  the  medical 
agitation  against  it;  we  often  see  patients  wear  them  and  every  drug 
store  sells  them.  Not  only  do  the  poor  and  ostensibly  ignorant  classes 
make  use  of  them,  but  we  meet  them  among  so-called  educated  patients. 
They  become  habituated  to  this  excessive  covering  of  the  chest,  and 
perspire  freely.  When  they  attempt  to  remove  it  they  are  easily 
chilled,  which  is  responsible  for  many  of  the  catarrhal  complications 
which  occur  during  the  course  of  the  disease. 

In  the  beginning  of  the  treatment,  the  patient  is  to  be  discouraged 
from  such  practices.  He  is  to  be  told  with  due  emphasis  that  woolen 
underwear,  of  thickness  consistent  with  the  season  of  the  year  and  other 
meteorological  conditions,  is  all  that  is  necessary.  A  woolen  garment 
has  a  capacity  for  absorbing  considerable  moisture  without  feeling 
wet,  while  cotton  soon  becomes  saturated  with  moisture.  If  evapora- 
tion takes  place  suddenly,  the  body  is  chilled.  Some  patients  are 
unduly  irritated  by  wool  next  to  the  skin,  but  by  constant  wear  they 
overcome  this  difficulty.  Of  course  it  is  important  that  the  underwear 
worn  during  the  day  should  not  be  worn  during  the  night. 

All  sudden  changes  in  temperature  within  and  out  of  the  house  are 
to  be  met  by  changing  the  overgarments.  During  the  winter  a  fur 
coat  is  good,  and  can  be  purchased  for  about  the  same  price  as  a  good 
overcoat.  Those  taking  outdoor  treatment  on  a  reclining  chair  need 
extra  wraps  during  the  winter.  Carrington^  gives  a  complete  descrip- 
tion of  the  various  appliances  which  may  be  used  for  the  purpose. 

Women  are  less  easily  managed  in  regard  to  clothing  than  men. 
The  low  cut  around  the  neck  and  chest  is  very  harmful  to  tuberculous 
women,  and  they  are  to  be  induced  to  forego  some  of  the  fashions  in 
vogue.  But  what  is  of  most  importance  is  the  corset,  which  many 
refuse  to  part  with,  claiming  that  it  is  not  at  all  the  figure  they  care 
for,  but  that  they  have  been  habituated  to  stays  and  feel  uncomfortable 
without  them.  But  when  explained  in  detail  the  way  a  corset,  even  of 
those  called  "hygienic,"  interferes  with  the  respiratory  movements 
of  the  thorax,  most  women  submit  to  the  argument. 

Smoking. — The  problem  whether  a  patient  who  has  been  found 
tuberculous  should  give  up  smoking  has  troubled  many  physicians 
in  sanatoriums.     Some  ha^'e  been  inclined  to  prohibit  it  indiscrimi- 

'  Journal  of  Outdoor  Life,  1912,  ix,  262. 


PERSONAL  HYGIENE  467 

nately,  and  failed,  as  a  rule.  One  who  has  been  habituated  for  long 
years  to  smoking  cannot  easily  give  it  up  and  when  he  does  he  is 
often  so  nervous  and  miserable  that  it  has  an  immense  influence  on 
his  general  well  being  and  the  course  of  the  disease!  The  fact  is  that 
smoking  has  no  deleterious  influence  on  the  tuberculous  process  in  the 
lungs,  and  there  is  no  reason  for  imposing  an  additional  hardship  on 
the  patient.    Of  course  chewing  tobacco  should  be  prohibited. 

When  there  are  laryngeal  complications  smoking  is  apt  to  cause 
irritation  and  cough.  However,  I  am  inclined  to  follow  Fetterolf's^ 
suggestion:  The  patient,  if  he  craves  for  his  cigar,  cigarette  or  pipe, 
is  thus  instructed:  "The  smoke  is  not  to  be  blown  through  the  nose  or 
inhaled;  that  if  a  cigar  or  cigarette  is  used  it  shall  be  smoked  in  a 
holder  at  least  four  inches  long,  and,  finally  that  the  smoking  be 
done  in  the  open  air.  The  main  evils,  barring  excess,  are  dry  heat 
and  dust  which  are  drawn  into  the  pharynx  and  larynx.  This  is  of 
greater  significance  the  shorter  the  smoked  article  grows,  and  if  the 
cigar  or  cigarette  is  used  in  a  holder  and  only  the  first  half  is  smoked, 
this  evil  is  largely  done  away  with."  It  is  Fetterolf's  belief  that  with 
such  precautions  as  just  mentioned  and  with  the  smoking  done  in  the 
open  air,  no  harm  will  result.  A  non-smoking  patient  in  a  close 
room  with  others  smoking  is  at  a  greater  disadvantage  than  one  who 
is  smoking  in  the  fresh  air. 

Occupation. — A  great  deal  has  been  said  of  occupations  fit  for  tuber- 
culous patients.  The  problem  is  not  one  which  concerns  those  with 
active  disease,  but  the  convalescents,  as  well  as  those  who  have  recov- 
ered. A  patient  during  the  active  course  of  phthisis  in  any  stage 
should  have  no  occupation  at  all.  He  cannot  work,  he  must  not  attend 
to  any  vocation  which  requires  physical  or  mental  exertion.  Mis- 
takes are  often  made  in  permitting  patients  in  the  incipient  stages  to 
wind  up  their  business,  to  finish  a  course  in  a  school,  etc.  This  is 
a  point  which  will  be  discussed  later  on  while  speaking  on  rest  and 
exercise  and  cannot  be  emphasized  too  strongly. 

It  is  very  difficult  to  advise  patients  who  have  recovered  from 
phthisis  as  to  their  future  activities  in  the  aft'airs  of  life.  With  the 
rich  9.nd  prosperous  the  matter  is  very  simple:  They  may  be  allowed 
to  return  to  their  vocations  provided  they  know  how  to  take  care  of 
themselves.  Under  supervision,  and  with  careful  observation  of  the 
ordinary  rules  of  healthy  life,  they  very  often  avoid  relapses.  The  same 
is  true  of  professional  people  who  can  resume  their  life  work,  perhaps 
at  a  slower  pace.  But  with  those  who  have  been  artisans,  manual 
laborers,  etc.,  especially  in  "precarious  occupations,"  the  matter  is 
different.  It  is,  indeed,  easy  to  advise  one  to  change  his  vocation, 
as  is  done  in  sanatoriums  when  patients  are  discharged,  but  whether 
the  patient  is  more  harmed  by  working  at  his  trade  and  earning  for 
his  support  than  by  starvation  because  of  lack  of  funds  to  buy  food, 
pay  for  his  lodging,  etc.,  is  hard  to  decide. 

1  Hare's  Modern  Treatment,  ii,  405. 


468 


GENERAL  MANAGEMENT  OF   THE  CASE 


Moreover,  a  change  of  occupation  is  not  feasible  in  the  vast  major- 
ity of  ^ases,  especially  with  skilled  artisans.  They  cannot  easily 
accept  low  wages  when  at  their  own  trade  the  pay  is  much  higher 
and  the  hours  shorter.  It  is  also  a  fact,  only  rarely  considered  by 
medical  men,  that  the  artisan  has  usually  adapted  his  organism  to  his 
peculiar  occupation;  in  fact  there  is  a  process  of  selection  going  on, 
certain  persons  are  attracted  to  certain  trades  at  which  they  succeed. 
They  must  return  to  these  occupations  after  recovering  from  the 
disease,  if  they  are  at  all  to  be  able  to  support  themselves.  And  they 
do,  in  fact,  in  spite  of  our  protestations. 

But  we  must  try  to  keep  convalescing  tuberculous  patients  from 
hard  muscular  exertion,  if  relapses  are  to  be  avoided.  They  are  to 
be  under  medical  supervision  for  several  months  after  beginning 
to  work  and  if  they  show  any  signs  of  damage  to  their  constitution, 
expecially  fever,  dyspnea,  tachycardia,  etc.,  they  must  stop  before 
it  is  too  late.  Nor  should  a  cured  patient  be  allowed  to  work  at  any 
dusty  trade,  such  as  pottery  and  earthenware  manufacture,  cutlery 
and  file  making,  certain  departments  of  glass  making,  copper,  iron, 
lead  and  steel  manufacture,  stone  cutting,  textile  trades,  fur-  or  cigar- 
making,  iron-grinding,  etc.  We  have  seen  the  effects  of  organic, 
mineral  and  metallic  dust  in  the  direction  of  engendering  a  soil  suscep- 
tible to  phthisis.  When  we  bear  in  mind  that  a  patient  with  cured 
tuberculosis  almost  always  harbors  virulent  tubercle  bacilli  in  the  cica- 
trized area  of  the  lung,  we  can  easily  understand  that  irritating  dust 
may  at  any  time  flare  up  a  dormant  lesion  into  renewed  activity  or 
cause  metastasis. 


Occupations  for 

Arrested  Cases  of  Tuberculosis. 

(W.    J.    VOGELER.) 

Healthy. 

Unhealthy. 

Healthy. 

Comparatively 
healthy. 

A 
Because  of 
occupation. 

B 

Factors  connected 
with  occupation. 

C 

To  employer,  etc. 

Artificial    flower 

Attendant   in   in- 

Brakeman 

Brewery  hand 

Child's  nurse 

maker 

sane  asylum 

Bridge  builder 

Dyer 

Baker 

Banker 

Bowling-alley  at- 

Caisson worker 

Emery-wheel 

Hairdresser 

Barber 

tendant 

Canvasser 

worker 

Fish  cleaner 

Bone-carver 

Boxmaker 

Car  conductor 

Garage 

Grocer 

Bookbinder 

Braider 

Cigarmaker 

Gasworks  em- 

Ice-cream vender 

Bookkeeper 

Brass  worker 

Coalyard  em- 

ployee 

Iceman 

Bootblack 

Bricklayer 

ployee 

Glassblower  em- 

Ice manufacturer 

Broker 

Brickmaker 

Collector 

ployee 

Milkman 

Broom-maker 

Cap  maker 

Constable 

Laboratory  em- 

Nurse 

(broom  and 

Carpenter 

Courier 

ployee 

Midwife 

brush  maker) 

Carriage  maker 

Driver 

Marble  worker 

Oysterman 

Business  man 

Cementer 

Drayman 

Stone-cutter 

Seamstress 

(merchant    and 

Chemist 

Horseman 

Miner 

Butcher 

dealer,       retail 

Electrical  worker 

Teamster 

Pool-room  atten- 

Candymaker 

and  wholesale) 

Elevator  employee 

Engineer 

dant 

Cook 

Butler 

Fireman  (fireman 

Expressman 

Printer 

Druggist 

Buttonhole  maker 

and  engineer) 

Farmer 

Rag-sorter 

Spice-room  worker 

Cabinet-maker 

Gasfitter 

Hostler 

Reporter 

Nurses  (trained) 

Chair-caner 

Glazier 

Huckster 

Riveter 

Chambermaid 

Gold  preparer 

Inspector 

Sailor 

Clergyman 

Harness  maker 

Iron  worker 

Scissors-grinder 

Clerk   (clerk   and 

(saddle  maker 

Janitor 

Stage  hand 

copyist) 

and  repairer) 

Junk  dealer 

Stone-cutter 

Cloth  examiner 

Houseworker 

Letter  carrier 

Type-polisher 

Cooper 

Lamp  cleaner 

Lineman 

Typesetter 

Coppersmith  (cop- 

Laundry worker 

Longshoreman 

Woolsorter 

per  worker) 

(male  and  fe- 

Lumber-yard em- 

Wine dealer 

Cutter 

male) 

ployee 

Detective 

PERSONAL  HYGIENE 


469 


Occupations  fok  Arrested  Cases  of  Txtberculosis — Continued. 


Healthy. 

Unhealthy. 

Healthy.- 

Comparatively 
healthy. 

A 

Because  of 
occupation. 

B 

Factors  connected 
with  occupation. 

C 

To  employer,  etc. 

Decorator 

Masseur 

Messenger  boy 

Hotel  and  board- 

Designer    (archi- 

Mechanic 

Motorman 

ing-house  keep- 

tect,   designer, 

Mill  hand 

Mover 

ers 

and    draughts- 

Molder 

Musician 

Saloon  and  restau- 

man) 

Oilworks  em- 

Navy employee 

rant  keepers 

Dressmaker 

ployee 

Newspaper  vender 

Livery  stable 

Engraver 

Operator 

Painter 

keepers 

Embroiderer 

Packer 

Peddler 

Tobacco  workers 

Factory  hand 

Paperhanger 

Plumber 

Foreman  (mill) 

Penmaker 

Policeman 

Garderner 

Pipe-cutter 

Watchman 

Hatter    (hat   and 

Plasterer 

Porter 

capmaker) 

Plaster-of-Paris 

Rigger 

Jeweler 

worker 

Salesman 

Labeler 

Rubber-maker 

Saleswoman 

Labor  boss 

Sawyer 

Scrubber 

Laborer  (labor 

Seamstress 

Shipper 

not  specified) 

Statue-painter 

Shipwright 

Lawyer 

Steamfitter 

Signalman 

Leather  worker 

Stereotyper 

Soldier 

(currier  and 

Terra-cotta 

Steel  worker 

tanner) 

worker 

Stevedore 

Librarian 

Tin-roofer 

Stoker 

Lithographer 

Trunkmaker 

Street-cleaner 

Locksmith 

Waiter 

Street-paver 

Machinist 

Washerwoman 

Tool-sharpener 

Merchants  and 

Wheelwright 

Undertaker 

dealers 

Chicken-farming 

Veterinarian 

* 

Metal  worker 

Window-cleaner 
Wood-chopper 

Milliner 

Morocco  finisher 

Lumberman 
Raftsman 

Nickel-plater 

Office-boy 

Miller 

Officials   of   com- 

Auctioneer 
Vine-grower 

pany 

Oilcloth  worker 

Compositor 
Pressman     ( 
Newspaper  work 

Optician 

Photographer 

Physicians  and 

surgeons 

Picture-frame 

maker 

Presser 

Servant 

School-child 

Shirtmaker  (shirt 

and  collar  and 

cuff  maker) 

Shoemaker 

Springmaker 

Stand-keeper 

Stenographer 

(stenographer 

and  typewriter) 

Storekeeper's  erii- 

ployee 

Student 

Suspender  maker 

Tailor 

Teacher   (teacher 

and     professor 

in  college) 

Telegraph  opera- 

tor   (telephone 

and  telegraph) 

Telephone  opera- 

tor    (telegraph 

and  telephone) 

Time-keeper 

Tin-plater      (tin- 

plate   and    tin- 

ware worker) 

Tinsmith 

Truss-maker 

Upholsterer 

Violin-maker 

Watchmaker 

Weaver 

Woodworker 

Wrapper 

470  GENERAL  MANAGEMENT  OF   THE  CASE 

Special  efforts  should  be  made  to  find  outdoor  employment  for 
patients  cured  from  tuberculosis.  It  is  always  to  be  remembered  that 
farming  is  not  the  only  outdoor  work,  nor  is  it  the  best.  Farm  labor- 
ers usually  work  very  hard  for  long  hours,  small  pay  and  with  food 
that  does  not  satisfy  the  city  dweller.  In  addition,  as  has  been  pointed 
out  by  Vogeler,^  the  lack  of  amusement  during  the  hours  of  recreation, 
and  the  enervating  heat  during  the  summer  are  serious  drawbacks. 
Of  course  it  is  different  when  the  patient  can  raise  funds  to  buy  or 
lease  a  farm  for  himself. 

There  are  in  cities  many  more  or  legs  remunerative  occupations 
which  are  suitable  for  this  class  of  cases,  as  conductors,  motormen, 
ticket  agents,  attendants  at  ferries,  watchmen,  solicitors,  etc.  My 
observations  lead  me  to  the  conviction  that  workers  at  the  garment 
industries,  excepting  at  fur,  may  safely  return  to  their  occupations, 
provided  they  find  employment  in  light  and  well-ventilated  workshops. 
The  same  is  true  of  the  building  industry,  provided  the  exposure  to 
the  vicissitudes  of  the  weather  is  not  excessive,  nor  the  hours  too 
long;  and  of  clerks,  salespersons,  etc.  Indeed,  I  have  been  struck 
with  the  fact  that  when  a  patient  who  recovered  from  phthisis  is 
unable  to  pursue  the  vocation  for  which  he  has  been  trained  for  many 
years,  he  will  not  do  well,  even  if  he  remains  idle  indefinitely. 

The  list  of  occupations,  compiled  by  Dr.  W.  J.  Vogeler,  and  repro- 
duced on  p.  468,  may  be  consulted  when  considering  a  suitable  occu- 
pation for  a  convalescing  or  cured  patient. 

In  judging  a  patient  with  a  view  of  selecting  an  occupation  for  him, 
we  may  be  guided  by  the  condition  of  his  temperature,  pulse,  respira- 
tion, and  general  constitution,  but  the  extent  of  the  lesion  is  a  hazard- 
ous criterion.  All  who  have  had  experience  agree  with  H.  M.  King 
that  "it  frequently  happens  that  a  satisfactory  condition  of  health 
as  determined  by  restoration  of  working  efficiency  maintained  for  many 
years  is  not  incompatible  with  physical  signs  which  of  themselves 
would  indicate  active  disease."  I  have  seen  many  cases  in  which  the 
reverse  was  true,  the  patient  showed  no  signs  of  active  disease  in  the 
lung,  yet  as  soon  as  he  began  to  work  he  broke  down  with  fever,  rapid 
pulse,  dyspnea,  etc.  These  patients  cannot  work  at  all.  Then  there 
are  others  who  will  work  for  several  months  and,  owing  to  an  evanes- 
cent, acute,  or  subacute  exacerbation,  are  laid  up  for  several  days  or 
weeks.  With  these  it  is  very  difficult  to  judge  the  ability  to  work. 
All  tuberculous  patients,  even  after  completely  recovering  from  the 
disease,  find  it  difficult  to  compete  with  healthy  persons,  but  the 
class  just  mentioned  is  more  apt  to  lose  in  the  struggle  for  existence. 
They  must  find  for  themselves  employment  of  a  nature  which  makes 
them  independent  of  strict  regularity. 

On  the  whole,  it  appears  that  cured  patients  do  best  when  return- 
ing to  their  old  vocation,  for  which  they  have  been  trained,  and  at 
which  they  can  earn  the  most  with  the  least  possible  effort.  It  may 
be  said  that,  with  some  striking  exceptions,  if  a  patient  is  not  able  to 
pursue  his  former  line  of  work,  he  is  altogether  disabled. 

1  National  Assn.  Study  and  Prcv.  Tuberc,  1912,  viii,  113. 


CHAPTER  XXXI. 
THE  REST  CURE. 

Principles  of  the  Rest  Cure. — We  know  that  nature  makes  a  strong 
effort  at  repairing  the  affected  lung  in  tuberculosis,  but  we  only  rarely 
think  of  the  method  it  pursues  when  doing  it.  Examining  the  chest  of 
a  tuberculous  patient,  we  find  on  inspection  that  there  is  a  strong 
tendency  to  putting  the  affected  area  of  the  lung  at  rest.  As  has 
already  has  been  shown,  during  the  early  stage  the  muscles  overlying 
the  pulmonary  lesion  are  almost  invariably  rigidly  and  spasmodically 
contracted.  This  contraction  has  been  ascribed  by  RubeP  to  the 
physiological  coordination  of  the  respiratory  centre.  It  inhibits  or 
prevents  the  motion  of  the  underlying  lung  to  a  certain  extent.  Later, 
pleural  adhesions  are  formed  which  impede  the  respiratory  movements 
of  the  lung  to  a  yet  greater  extent,  as  is  seen  in  the  lagging  of  the 
affected  side  of  the  chest,  offering  favorable  conditions  for  cicatriza- 
tion. This  immobilization  of  the  affected  part  of  the  lung  also  slows 
the  circulation  of  blood  and  lymph  in  that  area,  retains  the  bacteria 
and  their  toxic  products,  thus  lessening  toxemia  and  preventing 
metastatic  auto-infection  of  unaffected  parts  of  the  lung.  Rubel  has 
shown  experimentally  that  functional  rest  greatly  contributes  toward 
a  cure  of  tuberculous  lesions  in  the  lung.  He  immobilized  one  lung 
in  rabbits  and  then  infected  them  by  the  intravenous  way.  In  t)ie 
relatively  immobilized  lung,  the  lesion  was  found  to  be  of  the  chronic 
and  favorable  variety,  while  in  the  freely  movable  lung  it  was  acute 
and  progressive. 

Surgeons  have  utilized  physiological  and  functional  rest  in  the 
treatment  of  tuberculosis  of  bones  and  joints.  The  modern  treatment 
of  Pott's  disease  and  diseases  of  the  various  joints  consists  mainly 
in  affording  rest  to  the  affected  parts.  The  splint  has  done  better 
than  the  knife  in  these  forms  of  tuberculosis.  Formerly  physicians 
aimed  at  procuring  rest  in  tuberculous  diseases  of  the  thoracic  viscera 
by  the  application  of  strips  of  adhesive  plaster,  thus  immobilizing  the 
thorax;  and  at  present  the  induction  of  an  artificial  pneumothorax 
puts  the  affected  lung  at  complete  functional  rest.  "In  breathing  a 
normal  person  'opens  and  shuts'  the  lungs  nearly  30,000  times  a  day," 
says  Webb.  "By  rest  we  aim  to  make  the  breathing  as  shallow  as 
possible,  imitating  almost  that  of  hibernating." 

In  febrile  cases  rest  has  a  rationale  which  is  clear  to  everyone  who 

1  Ztschr.  f.  Tuberkulose,  1908,  x,  193,  319;  Roussky  Vratch,  1907,  vi,  648,  721,  750, 
896. 


472  THE  REST  CURE 

gives  some  thought  to  the  subject.  Fever  is  an  indication  of  activity 
of  the  tuberculous  process  and  results  from  absorption  of  toxins.  By 
keeping  the  patient  at  rest  we  reduce  the  frequency  and  depth  of 
respiration  and  thus  less  of  the  toxins  are  washed  into  the  blood 
stream  and  the  fever  declines.  With  the  reduction  in  the  fever,  there 
is  an  amelioration  in  the  cough,  and  an  improvement  in  the  appetite, 
resulting  in  better  nutrition  of  the  patient. 

Rest  and  Exercise  in  Phthisis. — ^In  former  days  the  treatment  of 
tuberculosis  consisted  mainly  in  removing  the  patient  to  some  country 
place,  or  better  yet  to  an  institution  and  urging  him  to  exercise  in  the 
open  air.  Thus,  the  main  principles  of  the  treatment  in  Brehmer's 
sanatorium  were  outdoor  exercise  for  long  hours,  daily  walking,  driv- 
ing, horseback  riding,  mountain  climbing  and  respiratory  exercises. 
The  same  methods  were  followed  in  institutional  and  home  treatment 
by  many  physicians  until  about  twenty  years  ago. 

The  development  of  sanatoriums  in  which  careful  observations 
have  been  made  on  the  effects  of  these  exercises  on  tuberculous 
patients  has  resulted  in  swinging  the  pendulum,  and  rest  has  come 
to  the  foreground  as  the  most  important  factor  in  combating  the 
disease,  so  that  at  present  vigorous  protests  are  heard  from  many 
sides  that  the  indolent  life  led  by  sanatorium  patients  is  often  more 
harmful  for  various  reasons  than  the  exercise  which  was  formerly  in 
vogue.  Indeed,  Paterson  reports  just  as  many  cures  at  Frimley  where 
the  patients  do  graduated  work,  as  in  sanatoriums  in  which  they  are 
kept  at  perfect  rest  for  long  months  or  even  years. 

The  contradictory  evidence  in  favor  of  rest  or  work  is  evidently 
due  to  the  fact  that  neither  rest  nor  exercise  is  a  panacea  which  will 
help  in  every  case,  but  that  each  has  its  indications  and  contra-indica- 
tions.  When  patients  presenting  symptoms  of  active  and  progressive 
phthisis — fever,  anorexia,  emaciation,  etc. — are  urged  to  work  or 
exercise,  considerable  harm  is  often  done,  and  a  favorable  case  may 
thus  be  converted  into  one  which  is  decidedly  hopeless.  In  the 
later  stages  of  the  disease,  when  the  lesion  has  localized  itself,  and 
the  patient  has  no  fever,  eats  well  and  feels  strong  enough  to  do  some 
work,  perfect  rest  may  be  distinctly  harmful,  as  will  be  pointed  out 
later  on.  Rest  and  exercise  have  their  indications  and  contra- 
indications. 

Indications  for  Rest. — Nature  puts  most  patients  who  suffer  from 
active  and  acute  forms  of  the  disease  at  rest.  They  are  weak,  anemic, 
emaciated,  and  the  exhausting  cough,  the  dyspnea,  and  the  phenom- 
ena of  toxemia  in  general,  preclude  any  kind  of  exercise.  But  in  the 
chronic  cases,  or  even  in  some  of  the  subacute  cases,  the  patient  may 
not  realize  his  plight  and  continue  working  at  his  occupation  until 
he  breaks  down,  when  it  is  too  late  to  recoup  the  lost  fiesh  and  forces. 
Rest,  properly  applied,  in  this  class  of  cases  may  be  life  saving. 

It  is  clear  that  all  active  cases  with  fever,  tachycardia,  anorexia 
emaciation,  weakness,  etc.,  are  to  be  kept  strictly  at  rest  until  most 


REST  AND  EXERCISE  IN  PHTHISIS  473 

of  these  symptoms  have  disappeared.  But  it  must  be  stated  at  the 
outset  that  the  extent  of  the  lesion  is  no  rehable  criterion  as  to  the 
indications  for  rest  and  exercise.  A  patient  in  the  incipient  stage,  with 
a  hmited  and  circumscribed  small  lesion  at  one  apex,  and  suffering 
from  fever,  dyspnea,  anorexia,  etc.,  is  often  more  harmed  by  work 
or  exercises  than  one  in  the  advanced  stages  with  extensive  involve- 
ment of  both  lungs,  but  with  normal  pulse  and  temperature. 

With  but  few  exceptions,  the  rate  of  the  pulse  is  as  good  an  index 
of  the  fitness  of  the  patient  to  work  as  there  is.  As  long  as  it  is  90  or 
over  per  minute,  or  it  is  accelerated  to  that  rate  by  mild  exercises,  the 
prognosis  is  not  good,  unless  the  patient  is  kept  at  perfect  rest.  In 
tuberculosis  we  often  meet  with  unstable  tachycardia ;  the  pulse  runs 
up  to  120  or  more  per  minute  at  the  least  exertion  or  excitement. 
Such  patients  are  to  be  kept  in  bed  or  on  the  reclining  chair,  until  we 
find  that  mild  exercises,  like  walking  slowly  on  level  ground  for  a  half 
or  one  mile  does  not  unduly  accelerate  the  pulse.  Some  of  these  cases 
with  tachycardia  are  afebrile,  the  temperature  is  in  fact  very  often 
below  normal  and  exercise  may  not  affect  it,  but  the  pulse  is  accel- 
erated on  the  least  exertion. 

Dyspnea,  when  present,  is  another  sign  that  the  patient  must  be 
kept  at  rest.  We  must  be  guarded  and  not  wait  for  subjective  dyspnea, 
because  many  tuberculous  patients  have  adapted  themselves  so  well 
to  their  difficulties  in  breathing,  that  they  are  not  much  disturbed 
by  it,  and  when  seen  to  breathe  very  superficially  and  rapidly,  even 
more  than  thirty  times  per  minute,  they  may  inform  us  that  they 
suffer  no  inconvenience  in  this  respect.  It  is  objective  dyspnea  which 
should  guide  us  in  our  estimation  of  the  effects  of  rest  or  exercise  in 
tuberculous  patients. 

Fever  has  been  considered  an  indication  for  rest  by  most  writers 
on  the  subject;  in  fact  the  problems  of  exercise  and  rest  have  usually 
been  solved  by  the  thermometer.  In  cases  of  tuberculosis  in  which 
the  temperature  reaches  100°  F.  the  patient  is  put  to  bed  and  kept 
there  till  it  descends  to  normal.  In  acute  cases  with  continuous  fever, 
or  during  acute  exacerbations  in  chronic  cases,  or  when  some  compli- 
cation ensues,  such  as  pleurisy,  or  any  non-tuberculous  infection, 
complete  rest  is  enjoined  till  the  fever  abates.  In  far-advanced  cases 
with  hectic  fever,  reaching  a  high  degree  in  the  afternoon  or  evening 
and  dropping  to  normal  or  even  below  in  the  early  morning  hours, 
the  patient  is  to  be  kept  in  bed  at  absolute  rest.  There  are,  however, 
cases  of  tuberculosis  with  fever  which  do  not  require  strict  rest.  They 
are  discussed  in  detail  elsewhere,  while  speaking  of  the  treatment  of  fever. 

Technic. — The  rest  cure,  when  indicated,  is  to  be  carried  out 
methodically.  In  acute  progressive  cases  it  means  complete  rest  in 
bed  until  the  temperature  declines  to  below  100°  F.  Some  patients 
revolt,  saying  that  they  feel  strong  enough  to  walk  around  for  several 
hours  of  the  day,  that  they  are  lonesome  and  would  surely  improve 
if  they  were  permitted  to  assume  the  erect  position  for  some  time. 


474  THE  REST  CURE 

But  they  are  to  be  told  that  fever  cannot  be  cured  outside  of  the  bed, 
and  as  Poujade  said:  "Undoubtedly  prolonged  rest  in  bed  weakens 
a  patient,  but  it  weakens  less  than  fever  which  kills." 

In  the  home  of  the  patient  it  is  advisable,  when  feasible,  to  have 
two  beds,  in  one  of  which  he  sleeps  during  the  night,  and  in  the 
other  he  spends  the  day.  Considering  that  the  patient  may  have 
to  remain  in  bed  for  weeks  or  months,  the  enforced  solitude  is  hard 
on  him,  and  the  change  of  the  bed  has  some  salutary  effect.  ^lore- 
over,  these  patients  are  apt  to  sleep  during  the  day  and  suffer  from 
insomnia  daring  the  night.  By  changing  the  room  and  bed  they  often 
become  habituated  to  sleep  in  one  bed  and  remain  awake  during  the 
day  in  the  other.  One  room  and  bed  may  also  be  aired  while  the 
other  is  used. 

In  the  morning,  when  the  patient  wakes,  he  is  to  be  given  a  sponge 
bath — one  with  alcohol  is  invigorating — and  dressed,  the  lower  half 
of  the  window  opened  and  the  bed  placed  in  such  a  position  that  he 
can  look  out  on  the  living  world.  If  he  feels  cold,  a  hot- water  bag  may 
be  placed  at  his  feet.  Great  care  must  be  taken  to  prevent  bed-sores 
in  prolonged  and  advanced  cases. 

When  the  temperature  descends  below  100°  F.,  or  even  in  prolonged 
cases  when  it  reaches  this  degree  only  at  a  certain  time  in  the  afternoon, 
but  is  near  normal  during  the  rest  of  the  day,  the  patient  may  be 
kept  at  rest  on  a  reclining  chair  during  the  greater  part  of  the  day, 
preferably  outdoors,  and  reading  and  mild  games  may  be  allowed; 
only  during  the  hours  when  the  rise  in  temperature  is  expected  is  he 
to  be  made  to  go  to  bed.  AYhen  we  find  that  this  does  not  increase 
the  fever,  he  may  be  permitted  mild  exercises,  such  as  short  walks, 
and  the  effects  should  be  watched.  We  are  often  surprised  to  find 
that  the  fever  disappears  altogether  with  mild  exercises. 

This  rest  in  bed  is  at  times  very  difficult  to  carry  out.  The  poor  are 
often  working  for  weeks  while  the  temperature  is  high — I  have  seen 
them  working  with  fever  of  103°  F.  and  even  higher.  When  beyond 
control  in  this  regard,  the  patient  is  to  be  sent  to  an  institution,  or 
to  one  of  the  day  and  night  camps.  I  have  seen  excellent  results  in 
such  cases  after  the  patient  has  been  at  one  of  these  institutions 
for  a  few  months.  Not  only  has  the  fever  disappeared,  but  the  patient 
was  educated  to  appreciate  the  dangers  of  exercises  during  the  febrile 
stage.  But  the  well-to-do  are  not  better  in  this  respect,  ^^e^y  often 
we  find  them  walking  around,  and  even  dissipating,  in  spite  of  the 
fact  that  their  temperature  is  above  102°  F.  Indeed,  they  are  often 
less  amenable  to  reason  in  this  respect  than  the  poor.  They  are  to  be 
impressed  that  all  business  and  pleasures  are  to  be  given  up  when  the 
temperature  is  high. 

Contra-indications. — It  was  one  of  the  great  mistakes  of  many  sana- 
toriums  to  urge  all  patients  to  keep  at  perfect  rest  and  abstain  from 
work  or  exercises,  irrespective  of  the  form  of  the  disease  and  the 
constitutional  symptoms.    The  result  was  that  they  turned  out  lazy 


EXERCISE  475 

people — hypochondriacs — who  feared  work  and  who  at  the  least 
fatigue  considered  themselves  harmed  by  it  after  they  had  been  cured. 
In  most  sanatoriums  of  today  strong  efforts  are  being  made  to  avoid 
such  mistakes. 

As  was  already  stated,  the  extent  of  the  lesion  is  not  always  an 
index  as  to  the  indications  for  rest.  There  are  many  patients  with 
extensive  lesions  in  the  lung,  in  fact  with  large  excavations,  who  are 
well  able  to  make  themselves  useful  along  certain  lines.  In  fact,  there 
are  cases  in  which  prolonged  rest  is  distinctly  harmful.  The  nervous 
system  may  be  functionally  damaged  beyond  repair,  the  desire  for 
activity  may  be  stifled,  and  the  resistance  of  the  body  in  general  may 
be  lowered.  It  has  also  been  shown  by  Paterson  and  Inman  that 
prolonged  rest  deprives  the  patient  of  certain  reactions  which  bodily 
activity  calls  forth  in  the  pulmonary  lesions  and  which  are  of  great  use 
in  combating  the  deleterious  efl^ects  of  the  disease. 

In  some  sanatoriums  where  the  rest  cure  has  been  carried  to 
excess  we  often  meet  with  patients  who  after  remaining  in  bed  or 
on  the  reclining  chair  for  several  months,  become  mentall}^  tired  and 
listless;  they  lack  interest  in  current  affairs;  others  become  hypo- 
chondriacs, consulting  the  thermometer  several  times  a  day  and  are 
alarmed  at  each  finding  above  or  below  normal.  They  often  lose  all 
hope  of  ever  getting  cured  and  this  despondency  contributes  greatly 
to  the  unfavorable  course  of  the  disease. 

The  graduates  of  sanatoriums  in  which  the  rest  cure  is  carried  to 
excess  are  apt  to  be  lazy  for  the  rest  of  their  lives.  Some  of  them, 
discharged  from  one  institution  immediately  seek  admission  to  another. 
As  Herman  M.  Biggs  says:  "A  sick  workman  is  converted  into  a 
healthy  loafer."  They  fear  muscular  exercise  of  any  kind  and  imagine 
tliat  the  least  work  aggravates  their  condition.  In  the  State  and 
municipal  institutions  in  this  country  w^e  find  many  with  a  record 
of  having  been  in  several  sanatoriums.  In  fact,  prolonged  rest  dis- 
ables any  human  being,  because  the  muscles  become  stiff  and  any 
attempt  to  walk  produces  muscular  weakness,  pains  and  aches  in 
the  limbs.  In  some,  the  long  rest  favors  the  deposition  of  fat,  which 
is  very  encouraging,  but  when  carried  to  excess,  which  is  not  a  very 
rare  phenomenon  among  the  tuberculous,  it  may  disable  the  patient 
as  much  as  active  phthisis.  These  patients  must  have  exercises  to 
reduce  the  fat.  This  is  mainly  seen  in  patients  in  whom  the  disease 
may  or  may  not  be  active,  but  at  any  rate  is  not  progressive ;  the  lesion 
has  become  quiescent,  completely  surrounded  by  connective  tissue. 
Rest  may  only  produce  obesity  of  various  degrees,  but  does  not  assist 
in  the  healing  of  the  disease  focus  in  the  lung.  It  is  in  these  cases 
that  graduated  work  or  any  exercise  will  do  more  than  rest,  and 
McLean's  aphorism  "if  the  phthisical  patient  would  live,  he  must 
work  for  it,"  is  confirmed. 

Exercise. — When  the  temperature  and  pulse  become  normal  and 
remain  so  for  several  days,  walking  exercises  are  to  be  commenced, 


476  THE  REST  CURE 

with  a  view  of  preventing  the  deleterious  effects  of  idleness  as  well 
as  provoking  mild  reactions — auto-inoculations,  which  are,  in  most 
cases,  of  immense  benefit.  At  first  the  patient  is  allowed  to  walk  a 
mile  on  level  ground  and  the  effects  on  the  temperature  and  pulse  are 
watched.  It  may  be  done  during  the  morning  hours,  when  the  tem- 
perature is  normal,  while  in  the  afternoon,  when  there  is  some  fever, 
the  patient  is  ordered  to  rest  on  a  reclining  chair,  or  even  in  bed.  But 
in  those  in  whom  the  afternoon  temperature  is  mild,  below  99°  F., 
even  this  precaution  need  not  be  taken,  provided  the  pulse  is  below 
85  per  minute. 

The  following  schedule  for  walking  exercises,  modified  after  that 
given  by  E.  Hyslop  Thomson,^  may  guide  the  patient  who  takes  his 
own  temperature : 

{98.5  or  lower;  long  or  medium  walk. 
99.0;  short  walk. 
99.5;  rest  outdoors  or  short  walk  around  house. 
100.0  or  higher;  remain  in  bed. 

f    99.0  or  lower;  medium  or  short  walk. 
Temperature  at  noon  <|     99.5 ;  short  walk. 

[  100.0  or  higher;  rest  in  bed  or  reclining  chair. 

Evening  temperature     (    99.5;  only  short  walk  on  the  following  day. 

at  7  P.M.  \  100.0  and  above;  complete  rest  during  following  day. 

Hill  climbing,  or  walking  long  distances,  up  to  fifteen  miles  a  day  in 
afebrile  cases  without  tachycardia  may  be  permitted.  The  author  has 
thus  tested  patients  as  to  their  ability  to  work,  and  was  surprised  to 
find  often  that  they  were  rather  invigorated  by  the  exercise  and  they 
were  then  allowed  to  work  for  their  support.  Our  patients  are  told 
to  come  to  the  office  on  foot,  walking  a  mile  or  two,  and  if  when  they 
arrive  the  pulse  and  temperature  are  found  normal,  they  are  told  to 
walk  a  longer  distance  the  next  day,  etc.  When  this  test  shows  that 
no  harm  is  done  by  the  exercises  the  patients  are  allowed  to  work, 
first  under  supervision,  and  later  completely  discharged  with  instruc- 
tions as  to  the  signs  of  danger. 

Graduated  Labor.  —  Practitioners  among  people  in  large  cities  are 
often  impressed  with  the  capacity  for  work  of  many  consumptives 
amid  unfavorable  surroundings  for  years  without  visible  harm.  Among 
these  cases  there  are  many  who  are  evidently  active  but  not  progres- 
sive; some  are  entirely  quiescent.  We  must  repeat  that  the  extent  of 
the  lesion  is  less  of  an  index  as  to  the  capacity  for  work  than  its  activ- 
ity as  revealed  by  the  constitutional  symptoms,  such  as  fever,  tachy- 
cardia, dyspnea,  etc.  Paterson^  developed  his  system  of  graduated 
labor  after  observing  such  cases  in  England.  "It  occurred  to  me," 
he  says,  "that  if  some  consumptive  persons  under  adverse  circum- 
stances, and  without  any  medical  guidance,  could  act  thus  without 

^  Consumption  in  General  Practice,  London,  1912,  p.  22.3. 
2  Sixth  Intern.  Congr.  Tuberc,  1908,  i,  886. 


■      EXERCISE  477 

apparent  injury,  they  ought,  under  ideal  conditions  and  with  the  work 
carefully  graduated  in  accordance  with  their  physical  state,  to  be  able 
to  undertake  useful  labor.  On  this  assumption  manual  work  should 
be  of  great  advantage  to  patients  undergoing  treatment  in  a  sanator- 
ium, as,  at  first,  it  would  do  much  to  meet  the  objection  that  mem- 
bers of  the  working  classes  are  liable  to  have  their  energy  sapped,  and 
to  acquire  lazy  habits  by  such  treatment;  second,  it  would  make  them 
more  resistant  to  the  disease  by  improving  their  physical  condition; 
and  third,  would  enable  them  by  its  effects  upon  their  muscles,  to 
return  to  their  work  immediately  after  their  discharge." 

With  a  view  to  developing  the  muscles  of  the  upper  limbs,  which 
are  supposed  to  have  more  direct  influence  on  the  expansion  of  the 
lungs,  Paterson  is  not  satisfied  with  walking  alone.  When  a  patient 
is  found  to  be  able  to  walk  ten  miles  a  day  without  aggravating  his 
condition,  he  is  given  a  basket  in  which  to  carry  mold  for  spreading 
on  the  lawns,  etc.  No  case  of  hemoptysis  or  of  pyrexia  occurred 
among  these  patients.  When  they  had  been  on  this  grade  with  noth- 
ing but  beneficial  results  for  from  three  weeks  to  a  month,  they  are 
given  boys'  spades  with  which  to  dig  for  five  minutes,  followed  by  an 
interval  of  five  minutes  for  a  rest.  After  a  few  weeks,  several  of  the 
patients  on  this  work,  who  were  doing  well,  were  allowed  to  work  as 
hard  as  possible  with  their  small  spades  without  any  intervals  of  rest. 
As  they  had  all  improved  on  this  labor,  larger  shovels  were  obtained, 
and  it  was  found  that  these  patients  were  able  to  use  them  without 
the  occurrence  of  hemoptysis  or  of  a  rise  in  temperature.  About  this 
time  many  of  the  patients  were  feeling  so  well  that  it  became  neces- 
sary to  restrain  them  from  doing  too  much. 

Paterson  worked  out  a  schedule  for  graded  work  which  brought 
excellent  results.  It  was  noted  that  many  patients  on  their  arrival 
are  somewhat  remarkable  for  a  somewhat  sullen  and  apathetic  atti- 
tude, but  as  soon  as  their  physical  condition  undergoes  amelioration, 
all  traces  of  gloom  and  depression  leave  them  and  they  become  lively, 
cheerful  individuals.  In  many  cases  in  which  the  improvement  was 
not  prompt,  the  effect  of  harder  work  was  tried  and  often  a  progressive 
improvement  was  noted  at  once.  Paterson  found  that  the  danger 
signals  are:  a  temperature  of  99°  F.  or  higher  in  men  and  99.6°  F.  in 
women,  loss  of  appetite  and  slight  headache.  As  soon  as  these  appear 
the  patient  is  to  be  put  to  bed  till  the  temperature  goes  down  to 
normal.  In  my  experience,  a  rapid  pulse  is  of  even  more  importance 
as  an  indication  that  exercises  are  deleterious. 

Inman,^  working  with  Wright's  method  of  ascertaining  the  opsonic 
index  in  patients  under  this  graded  work  system  of  Paterson,  found 
that  it  was  at  some  part  of  the  day  well  above  normal  and  he  explains 
it  as  due  to  the  stimulus  supplied  by  the  work,  inducing  artificial 
auto-inoculation;  that  the  organism  responds  by  the  the  production 

Sixth  Intern.  Congr.  Tuberc,  1908,  i,  901. 


478  THE  REST  CURE 

of  immune  bodies.  In  fact,  whenever  excessive  auto-inoculation  takes 
place  harm  is  done.  This,  he  points  out,  must  be  readily  recognized 
clinically,  if  harm  is  to  be  avoided.  "A  patient  doing  well  on  the 
grade  of  work  prescribed  for  him  and  with  no  abnormality  of  tem- 
perature suddenly  complains  of  feeling  tired,  of  loss  of  appetite  and 
of  headache;  and  the  temperature  chart  registers  an  elevation  to 
99°  or  100°  F.  These  are  precisely  the  symptoms  which  are  found 
during  the  negative  phase  after  excessive  dose  of  bacterial  vaccine." 

Paterson  is  guided  in  his  conduct  of  a  case  by  the  thermometer, 
and  whenever  the  temperature  registers  99°  and  over  in  men  and  99.6° 
in  women  (by  mouth),  the  patient  is  kept  strictly  in  bed.  When 
work  has  been  assigned,  the  temperature  is  watched,  and  as  long  as 
it  is  not  increased  by  the  exertion,  the  work  is  increased  in  duration 
and  intensity.  Even  afebrile  patients  who  are  of  poor  general  condi- 
tion are  not  allowed  to  work,  but  kept  at  perfect  rest,  excepting  that 
they  are  allowed  to  walk  to  and  from  the  dining  hall  for  their  meals. 

It  is  thus  evident  that  there  is  little  new  in  this  system  of  exercises 
and  work.  Physicians  have  always  allowed  their  afebrile  patients  who 
are  of  good  general  condition  and  not  easily  fatigued  to  work  and 
warned  them  to  stop  as  soon  as  symptoms  of  toxemia,  such  as  a 
tired  feeling,  weakness,  debility,  drowsiness  make  their  appearance. 
Intelligent  patients  have  been  given  thermometers  to  aid  them. 

Paterson's  method  has,  however,  done  a  great  deal  for  institutional 
patients  by  drawing  attention  to  the  importance  of  exercises  and  work 
in  attempts  at  prevention  of  indolence  which,  in  many  cases,  remains 
as  a  reminder  of  the  disease  and  the  institutional  life  to  which  they 
had  been  subjected. 

Outdoor  Games. — Afebrile  patients  without  tachycardia  are  to  be 
encouraged  to  do  some  exercise  in  the  open  air,  otherwise  they  are 
likely  to  brood  over  their  troubles,  and  in  some  cases  even  harmed 
by  obesity.  Walking  exercises  alone  are  often  insufficient  to  keep  the 
average  patient  busy,  and  outdoor  games  are  often  good  to  help  him 
pass  this  time  pleasantly  and  to  benefit  the  muscles,  the  appetite,  and 
the  metabolism. 

In  advising  a  patient  as  to  outdoor  games  we  must  always  consider 
his  life,  habits  and  customs  before  he  took  sick.  Those  who  indulged 
in  sports  may  be  permitted  to  resume  their  favorite  games,  provided 
they  do  not  raise  the  temperature  or  produce  breathlessness.  This 
at  once  excludes  certain  games.  "All  violent  sports  should  be 
avoided,"  says  Lawrason  Brown,  "Golf  (without  the  full  swing), 
croquet,  fishing  and  hunting  (not  entailing  too  much  exercise),  gentle 
bicycle  riding  (on  the  level),  rowing  or  paddling,  skating  (for  those 
proficient),  skiing,  snow  shoeing,  swimming  (in  great  moderation), 
and  horseback  riding,  may  be  indulged  in  with  moderation  when  the 
disease  has  been  arrested." 

It  seems  to  me  that  of  the  outdoor  games,  golf  is  the  best  for  patients 
who  have  just  recovered  from  phthisis.    Cricket,  football  and  athletic 


EXERCISE  479 

sports  in  general  produce  more  or  less  dyspnea,  while  golf  makes  less 
violent  demands  on  its  votaries,  and  is  usually  played  in  open  breezy 
places. 

Indoor  Games. — The  tuberculous  patient  is  to  be  allowed  some 
games  for  his  amusement  even  when  he  is  kept  indoors,  excepting  when 
the  temperature  is  above  100°  F.  and  he  is  kept  in  bed  during  the 
whole  day.  I  believe  it  is  wrong  to  interfere  with  them  when  they 
play  cards,  checkers  and  chess,  as  is  often  done  in  public  sanatoriums, 
on  the  assumption  that  the  excitement  is  liable  to  raise  the  temperature, 
provoke  hemoptysis,  etc.  While  it  cannot  be  said  that  these  games 
immunize  the  patients  against  such  accidents,  I  have  never  seen  such 
results  follow  when  they  are  allowed  to  have  some  amusement  during 
the  long,  lonesome  days  and  weeks  in  the  institution. 

Patients  .treated  at  home  are  not  to  be  allowed  to  go  to  theatres, 
or  other  indoor  and  badly  ventillated  places  of  amusement  as  long  as 
they  have  fever. 


CHAPTER  XXXII. 
OPEN-AIR  TREATMENT. 

Most  writers  state  that  Brelimer  was  the  first  to  demonstrate,  in 
1859  in  his  sanatorium,  the  great  value  of  the  open-air  method  of  treat- 
ment of  tuberculosis.  But  it  is  a  fact  that  he  had  many  precursors. 
In  1840  George  Bodington,  a  country  doctor  in  the  village  of  Erding- 
ton,  published  an  Essay  on  the  Treatment  and  Cure  of  Pulmonary 
Tuberculosis,  in  which  he  vigorously  protested  against  the  close  con- 
finement of  consumptives  for  fear  of  the  evil  influences  of  cold,  fresh 
air,  "forcing  them  to  breathe  over  and  over  again  the  same  foul  air 
contaminated  with  diseased  effluvia  of  their  own  persons."  Arguing 
against  the  value  of  antimony,  calomel  and  bleeding,  which  were  in 
vogue  in  those  days,  he  urged  the  free  administration  of  nutritious 
food  and  stimulants  with  plenty  of  exercise  in  pure  and,  if  possible, 
dry,  "frosty"  air.  In  short,  his  great  specific  in  phthisis  was  dry, 
cold  air  which,  he  said,  had  a  most  powerful  influence  in  "  healing  and 
closing  of  cavities  and  ulcers  of  the  lungs." 

Needless  to  say  he  was  severely  handled  by  his  contemporaries  and 
so  discouraged  that  he  had  to  give  up  his  method  of  treatment,  con- 
verting his  "sanatorium"  into  an  insane  asylum.  Brehmer  in  Ger- 
many and  Trudeau  in  the  United  States  later  took  up  work  along  the 
lines  of  Bodington  and  met  with  no  small  amount  of  opposition  and 
ridicule  from  the  contemporary  leaders  of  the  profession  and  the  laity. 

At  present  the  gospel  of  fresh  air  needs  no  evangelists  to  bring  it 
home  to  most  sufferers  from  phthisis;  it  is  the  acknowledged  corner- 
stone of  phthisiotherap3\  The  only  dift'erence  of  opinion  is  where  and 
how  it  can  be  applied  most  effectively.  Some  send  their  patients  to 
certain  regions  where  the  climate  is  alleged  to  have  a  specific  influence 
on  the  disease;  others  direct  them  to  sanatoriums  where  they  may 
benefit  by  both  the  climatic  advantages  and  certain  therapeutic 
methods  which  are  the  hobby  of  the  presiding  genius.  Many  are  con- 
vinced that  similar  advantages  may  be  obtained  at  the  home  of  the 
average  patient. 

Where  Open-air  Treatment  may  be  Obtained. — The  open-air  treat- 
ment consists  in  inducing  the  patient  to  live  permanently  in  pure, 
fresh  air,  preferably  outdoors  or,  when  he  must  stay  indoors,  the  air  in 
the  room  is  to  be  renewed  constantly.  There  is  no  question  but  that 
this  is  best  obtained  in  the  country  or  in  a  special  institution.  But 
most  patients  cannot  afford  to  leave  the  cit}^  for  an  indefinite  period, 
nor  are  there  a  sufficient  number  of  institutions  in  any  country  to 
accommodate  all  active  tuberculous  patients  with  places  for  as  long 


OPEN-AIR   VS.   CLIMATIC   TREATMENT  481 

as  the  disease  lasts.  In  fact,  if  all  the  patients  were  to  decide  that 
they  want  to  submit  to  hospitalization  for  therapeutic  or  prophylactic 
purposes,  it  would  be  found  that  only  a  small  fraction  of  the  eligible 
could  be  accommodated. 

Says  Edward  Cummings:^  "Personally  I  cannot  see  the  need  of 
banishing  the  tuberculous  patient  from  his  comfortable  chamber  to  a 
shack  in  the  back  yard,  or  a  woodshed,  or  a  tent  house  in  the  dusty 
desert.  One  does  not  always  have  to  go  across  the  continent  to  get 
fresh  air,  not  even  out  in  the  yard.  .  .  .  The  ordinary  bedroom 
for  most  persons  is  well  enough."  My  own  observations  in  large 
modern  cities  like  New  York,  Boston,  Chicago,  St.  Louis,  Philadelphia, 
London,  Manchester,  etc.,  have  convinced  me  that  results  can  be, 
and  are,  obtained  which  compare  favorably  with  climatic  and  institu- 
tional treatment.  Of  course  in  the  congested  districts  and  slums, 
the  overcrowded  tenements  are  even  less  suitable  for  consumptives 
than  they  are  for  human  habitation  in  general.  But  there  are  dis- 
tricts in  every  city  which  can  be  utilized  for  the  purpose  of  housing 
consumptives  and  the  results  attained  will  not  be  behind  those 
attained  after  sending  patients  far  away  from  their  homes  at  great 
expense  and  often  hardship.  Dr.  Thomas  Specs  Carrington  has 
done  a  great  deal  in  popularizing  suitable  methods  of  open-air 
treatment  for  consumptives  in  cities. 

The  suburbs  around  cities  are  suitable  for  families  in  which  there 
are  tuberculous  members  and  the  expense  involved  in  moving  them  to 
these  parts  is  comparatively  trifling;  in  fact  the  rent  is  often  lower, 
and  they  need  not  lose  their  jobs  or  break  up  their  business.  The 
social  and  economic  aspects  of  tuberculosis,  which  are  but  rarely  con- 
sidered in  this  connection,  assume  a  different  aspect  when  the  patient 
must  not  be  sent  far  away  from  home  or  from  the  place  of  employ- 
ment of  those  he  depends  on.  Lawrason  Brown^  thus  summarizes  the 
question:  "Treatment  at  home  is  less  expensive,  does  not  entail 
residence  in  a  hotel  or  boarding  house  or  '  acclimatization'  after  return 
to  work;  precludes  separation  from  the  family  and  friends,  fatigue 
of  travel,  homesickness;  does  not  break  up  business  arrangements  in 
the  same  degree." 

Open-air  vs.  Climatic  Treatment. — These  two  methods  must  be 
kept  distinctly  apart.  Experience  has  taught  that  there  is  no  climate 
on  the  habitable  globe  in  which  consumption  does  not  occur,  or  where 
a  patient  sick  with  the  disease  will  surely  recover,  even  when  sent 
thither  in  the  very  incipient  stage  of  the  ailment.  In  the  climatic 
resorts  which  have  become  popular — and  it  is  a  fact  that  the  popular- 
ity of  a  region  is  by  no  means  an  index  of  its  therapeutic  efScacy — the 
patient  must  subject  himself  to  a  certain  discipline  if  he  expects  results. 
Irrational  mode  of  life  in  the  mountains  or  at  the  sea  coast  will  aggra- 
vate the  condition  of  a  consumptive  to  the  same  extent  as  it  will  in  the 

1  Journal  of  Outdoor  Life,  1912,  ix,  257. 

2  Osier's  Modern  Medicine,  i,  487. 
31 


482  OPEN-AIR   TREATMENT 

city.  A  healthful  mode  of  life  in  any  place  will,  and  does,  improve  the 
condition  of  the  average  consumptive,  no  matter  where  he  is. 

The  treatment  of  tuberculosis  in  certain  climatic  regions,  as  we  shall 
see  later  on,  has  its  indications  and  contra-indications,  while  home 
treatment  has  certain  advantages  in  this  regard.  It  can  be  applied 
successfully  in  the  treatment  of  nearly  all  cases,  in  all  forms  of  phthisis, 
and  in  all  its  stages;  striking  results  are  obtained  in  patients  with 
limited  means  as  well  as  with  those  who  are  well-to-do;  in  febrile  and 
afebrile  cases;  in  hemorrhagic  and  cachectic  cases;  in  those  with  or 
without  gastric  derangements.  In  short,  in  all  cases  of  tuberculosis, 
in  all  its  forms,  in  all  stages  of  the  disease,  during  any  season  of  the 
year  in  almost  any  climate,  except  the  arid. 

To  be  successful,  it  must  be  applied  rigorously,  methodically  and 
properly  regulated  by  the  physician.  This  is  no  more  than  institutional 
treatment  depends  on,  excepting  that  the  former  is  cheaper  for  the 
community  which  is  charged  with  caring  for  its  consumptives  and 
more  attractive  to  many  who  have  sufficient  material  means  at  their 
command. 

Dangers  of  Stagnant  Air. — Our  conception  of  the  beneficial  effects 
of  indoor  life  has  undergone  radical  changes  during  recent  years.  The 
reasons  why  the  stagnant  air  in  a  room  occupied  by  human  beings 
is  harmful  are  not  clear.  Recent  investigations  by  Leonard  Hill, 
Haldane,  Benedict,  Fliigge,  C.  E.  A.  Winslow,  and  others  have  shown 
that  it  is  not  the  excess  of  carbon  dioxide,  or  the  decrease  in  the 
proportion  of  oxygen  which  renders  the  stagnant  air  harmful.  The 
most  deteriorated  air  in  a  badly  ventilated  room  never  shows  on 
analysis  as  much  as  1  per  cent,  of  carbon  dioxide,  while  in  famous 
health  resorts  at  high  altitude  there  is  a  far  greater  deficiency  of 
oxygen  than  can  ever  be  found  in  the  worst  ventilated  room.  The 
specific  organic  poisons  of  human  origin,  the  morbific  anthropotoxins, 
of  which  some  have  spoken,  have  never  been  isolated. 

As  Winslow^  points  out,  recent  studies  indicate  beyond  any  reason- 
able doubt  that  the  more  obvious  effects  experienced  in  a  badly  ven- 
tilated room  are  due  to  the  heat  and  moisture  produced  by  the  bodies 
of  the  occupants,  rather  than  to  the  carbon  dioxide  or  other  substances 
given  oft'  in  the  breath.  Two  fundamental  experiments  have  been 
repeated  again  and  again  which  would  suffice  to  demonstrate,  as  F. 
S.  Lee  has  so  well  expressed  it,  that  the  problem  of  ventilation  is  not 
chemical  but  physical — not  respiratory,  but  cutaneous.  These  are: 
First,  that  subjects  immured  in  close  chambers  and  exposed  to  heat 
as  well  as  the  chemical  products  formed  therein,  are  not  at  all  relieved 
by  breathing  pure  outdoor  air  through  a  tube;  and  second,  that 
they  are  completely  relieved  by  keeping  the  chamber  artificially  cool 
without  changing  the  air  at  all,  and  are  relieved  to  a  considerable 
extent  by  the  mere  cooling  effects  of  an  electric  fan. 

1  Science,  N.  S.,  1U15,  xli,  625. 


TECH  NIC  OF   TREATMENT  483 

Investigations  made  by  the  New  York  State  Commission  on 
Ventilation  have  shown  that  the  temperature  and  the  pulse  rate  of 
an  individual  are  markedly  increased  by  even  a  slight  increase  in  the 
room  temperature;  they  also  confirm  Leonard  Hill's  observations  that 
overheated  rooms  enhance  the  susceptibility  to  respiratory  diseases 
owing  to  changes  in  the  mucous  membrane  which  follow  exposure  to 
hot  and  dry  air,  and  the  resistance  of  animals  to  artificial  infection  is 
very  definitely  lowered  by  chill  following  exposure  to  a  hot  atmosphere. 

In  connection  with  tuberculosis,  in  which  the  appetite  is  of  such 
great  importance,  it  is  of  interest  that  stagnant  air  reduces  the 
desire  for  food  perceptibly.  In  two  series  of  experiments  made  by  the 
above-mentioned  Commission,  standard  luncheons  were  served  to 
the  subjects  in  the  experimental  chambers  and  the  amount  on  their 
plates  weighed.  In  one  series  the  subjects  consumed  on  the  stagnant 
days  an  average  of  1151  calories  and  on  the  fresh-air  days  an  average 
of  1308  calories,  an  increase  of  13  per  cent.  In  a  second  series  during 
colder  weather,  the  average  consumption  was  larger,  1492  calories 
for  the  stagnant  and  1620  calories  for  the  fresh-air  days. 

We  have  here  an  explanation  for  the  utility  of  fresh  air  in  the  treat- 
ment of  tuberculosis.  Stagnant  air  is  bad  primarily  because  of  its  high 
temperature  and  lack  of  cooling  air  movement,  sometimes  combined 
with  high  humidity.  In  fact  a  lack  of  humidity,  as  Phelps  has  pointed 
out,  makes  hot  air  feel  cooler  and  cold  air  feel  warmer.  It  is  very 
important  that  the  air  in  a  living  room  should  not  be  dry,  as  it  is  in 
most  of  our  artifically  heated  rooms  during  the  winter.  W.  Freuden- 
thaP  has  shown  the  dangers  of  dry  air  in  a  recent  study  of  the  subject. 
Living  in  stagnant  air  the  patient  feels  uncomfortable,  inert  and 
listless,  and  above  all,  loses  his  appetite  for  food,  which  is  very  essential 
in  the  treatment  of  phthisis.  The  open-air  treatment  seeks  to  remove 
the  drawbacks  of  indoor  life  amid  stagnant  air.  No  doubt  it  is  attained 
best  in  a  good  sanatorium,  but  it  may  be  just  as  well  attained  at  home 
within  the  city  lines  in  most  houses. 

Technic  of  Treatment. — If  the  patient  lives  in  a  capacious  home,  or 
in  one  in  which  he  may  have  a  fair-sized,  well-lighted,  and  ventilated 
room  to  himself,  in  a  district  or  street  which  is  not  overcrowded,  he 
may  remain  where  he  is.  But  in  case  he  lives  in  the  slum  district  of 
a  large  city,  in  a  dingy  and  overcrowded  tenement,  he  must  move  to 
better  quarters  which  are  available  in  every  city.  If  his  occupation, 
or  that  of  those  he  depends  on,  is  not  in  the  way,  it  is  even  better  that 
he  move  to  the  outskirts  of  the  city,  or  to  a  suburb  where  certain 
advantages  may  be  obtained  which  are  not  available  or  feasible  in  the 
city. 

A  few  words  should  be  said  about  the  various  shacks,  tents,  special 
window  tents,  etc.,  which  have  been  contrived  for  the  city  dweller 
with  a  view  of  giving  him  an  opportunity  to  live  outdoors  or  in  a  well- 

'  New  York  Med.  Jour.,  1914,  xcix,  1. 


484  OPEN-AIR   TREATMENT 

ventilated  room.  ]\Iost  of  them  are  not  feasible.  They  cannot  be 
used  in  the  thickly  inhabited  parts  of  cities;  the  tents  or  shacks  can- 
not be  placed  in  the  back  yards,  on  the  roofs,  etc.,  without  attracting 
the  curious,  or  even  exposing  the  patient  to  eviction  because  of  the 
resentment  of  the  neighbors.  I  have  seen  a  few  patients  in  New  York 
City  who  have  made  use  of  these  contrivances,  but  they  were  rare 
exceptions,  and  they  lived  in  private  dwellings  in  the  outskirts  of  the 
city. 

But  the  average  bedroom,  excepting  in  the  dingy  tenements,  is 
sufhcient  for  our  purposes.  If  the  patient  is  allowed  to  remove  the 
window  sashes,  both  the  upper  and  the  lower,  as  Cummings  suggested, 
he  may  convert  it  into  an  open-air  sleeping  quarters.  The  patient's 
room  should  be  large,  one  with  a  capacity  of  3000  to  3500  cubic  feet 
of  air  is  best.  But  it  must  always  be  remembered  that  cubic  space  is 
of  little  value  per  se  unless  it  is  provided  with  efficient  means  of 
ventilation. 

In  modern  apartments,  rooms  with  windows  opening  into  air  shafts 
or  narrow  courts  are  not  good  for  tuberculous  patients;  they  should 
have  rooms  with  windows  opening  into  the  street  or  a  spacious  court- 
yard. In  apartment  houses  with  elevators  the  top  floor  is  the  best, 
the  higher  the  building  the  better.  But  in  houses  without  elevators 
the  advantages  of  the  pure  air  in  the  upper  stories  are  often  negated 
by  the  exertion  necessary  in  stair  climbing  by  walking  patients;  but 
the  ground  floor  should  be  avoided.  It  should  also  be  seen  that  trees 
do  not  obstruct  the  entry  of  air  and  light  to  the  room  and  favor  exces- 
sive humidity.  The  windows  of  the  room  must  be  located  so  that  the 
sun's  rays  enter  them  for  at  least  part  of  the  day  and  penetrate  at  least 
ten  feet  into  the  room. 

The  walls  of  the  room  should  be  painted,  not  papered.  All  unneces- 
sary curtains  and  hangings  should  be  discarded,  leaving  nothing  but 
roller  shades  on  the  ^\'indows.  Carpets  are  obviously  bad,  but  some 
rugs  should  be  left  on  the  floor.  Bare  floors  are  apt  to  discourage  the 
patient  as  well  as  those  around  him.  The  rugs  can  be  taken  out  at 
frequent  intervals,  aired,  and  disinfected.  The  floor  should  be  waxed 
or  painted,  so  as  to  be  easily  cleaned.  Steam  or  hot-water  heating  is 
best;  gas  heating  is  to  be  avoided  because  it  consumes  oxygen  from 
the  air. 

Afebrile  patients  who  are  allowed  outdoor  exercises,  should  remain 
in  the  room  very  little  during  the  day.  In  the  city  they  are  to  leave 
their  room  soon  after  breakfast  and  go  to  some  neighboring  park  where 
they  are  to  spend  the  greater  part  of  the  day.  In  the  outskirts  of  the 
city,  or  in  the  suburbs  there  may  be  sufficient  space  around  the  house, 
as  well  as  porches,  balconies,  etc.,  on  which  they  may  exercise  and 
rest  comfortably,  reading  or  doing  some  light  work  under  careful 
supervision  of  the  physician.  Intelligent  patients  may  be  given 
thermometers  with  directions  to  guide  them  as  to  the  eftects  of  exercise 
or  work. 


TECH  NIC  OF  TREATMENT 


485 


The  season  of  the  year  has  httle  effect  on  the  outdoor  hfe.  The 
patient  is  to  spend  the  greater  part  of  the  day  outdoors  during  the 
winter  as  well  as  during  the  summer.  Only  intense  cold,  or  sun  rays, 
rain  or  strong  winds  are  to  be  avoided  by  seeking  shelter.  Excepting 
during  blizzards,  snow  is  rather  invigorating  to  the  average  patient 
of  this  class. 

Sleeping  Porches.— Those  living  in  the  outskirts  of  the  city  or  the 
suburbs,  may  have  tents  in  which  they  sleep  during  the  night  and  seek 
shelter  during  inclemencies  of  the  weather.  -But  the  usual  tent  is 
rather  stuffy  and  damp  for  a  tuberculous  patient.  There  are  made 
at  present  tent  houses,  or  canvas  bungalows,  which  are  excellent 
because  of  the  comforts  they  afford  and  the  good  ventilation  that  may 
be  had  within  them. 


Fig.  80. — A  knitted  helmet  for  protecting  the  head,  neck,  and  shoulders.     (T.  S. 

Carrington.) 

It  is,  however,  best  that  the  patient  remain  the  greater  part  of  the 
day  on  the  porch,  and  in  most  cases  he  may  sleep  in  a  bed  placed  on 
the  porch.  During  the  day,  in  case  perfect  rest  is  to  be  enjoined,  he 
may  remain  on  some  form  of  reclining  chair  of  which  there  are  at  present 
many  on  the  market,  such  as  the  Adirondack  Recliner,  the  Kalamazoo 
Chair,  the  common  hammock  chair,  the  willow  long  chair,  etc.  During 
the  cold  winter  he  may  also  remain  on  the  porch  on  one  of  these 
chairs  during  the  day,  and  in  a  bed  during  the  night.  "  The  whole 
problem  is  one  of  sufficient  bedclothes  and  the  use  of  some  sort  of 
hood  or  head  covering  (Fig.  80);  in  short,  to  dress  especially  for 
sleeping  out."  As  Cummings  suggests,  "  by  putting  on  a  suit  of  under- 
wear, a  flannel  shirt,  pajamas  of  outing  flannel,  and  a  hood  of  flannel 


486 


OPEN-AIR   TREATMENT 


or  eider-down,  and  furnishing  the  bed  with  plenty  of  hght  weight,  but 
warm  blankets  and  comfortables  one  can  sleep  with  a  continuous  flood 
of  fresh  air  in  severe  weather  and  perfect  comfort  and  safety." 

It  is  self-evident  that  sleeping  porches  are  only  feasible  in  rural 
districts,  and  not  in  large  cities,  excepting  in  their  outskirts.  But  it  is 
always  important  to  remember  that  the  proper  construction  of  a  sleep- 
ing porch  is  not  a  simple  matter.    A,  Morgan  MacWhinnie^  investi- 


OPEN 


\\                     SLEEPING                    ^^ 
.     ^\                   PORCH              ^^ 

\ 

BED  ROOM 

SCALE  X"=l'           ^^^ 

Fig.  81. — Porch  exposed  on  three  sides;   no  provision  for  keeping  the  bed  warm 
during  the  day.     (MacWhinnie.) 

gated  one  hundred  sleeping  porches  in  the  Northwest  and  found  the 
following  conditions:  In  96  cases  the  sides  of  the  sleeping  balcony 
were  partially  protected  from  the  wind  and  rain  by  a  tarpaulin  or 
some  other  material.  Two  had  no  protection  whatever,  and  one  was 
inclosed  with  glass  windows  which  could  be  thrown  open  horizontally 
at  night  on  retiring.    This  was  the  only  one  that  could  be  closed  in 


1  New  York  Med.  Jour.,  1914,  xcix,  780. 


TECH  NIC  OF  TREATMENT 


487 


the  daytime,  and  had  hot-water  radiators  connecting  with  the  boiler 
in  the  cellar  that  kept  the  bed  and  its  covering  as  warm  all  day  as  the 
rest  of  the  house.  In  98  cases  the  bed,  mattresses,  linen,  and  covers 
were  exposed  all  day  to  the  dampness  of  the  atmosphere.  I  found 
similar  conditions  in  most  of  sleeping  porches  in  the  East. 

The  warming  of  the  bedding  and  coverings,  and  keeping  them  dry  is 
an  element  which  is  very  often  neglected  in  open-air  treatment  and 
it  is  not  surprising  that  most  patients  do  not  want  to  sleep  outdoors 
on  cold  and  moist  days.     MacWhinnie  suggested  sleeping  porches 


OPEN  WEST 


Fig.  82. — Ideal  sleeping  porch.  When  the  bed  is  fully  extended  on  the  porch,  the 
footboard  closes  the  room  from  the  outside  air;  when  bed  is  in  warm  room,  headboard 
closes  opening  to  sleeping  porch.     (MacWhinnie.) 


which  have  none  of  these  disadvantages;  they  are  so  arranged  as  to 
be  completely  protected  from  the  weather.  He  urges  that  the  doors 
should  be  large  so  that  the  bed  can  be  kept  in  the  heated  room  during 
the  entire  day  so  that  the  bedding  is  warm  and  dry.  When  ready  for 
the  night,  it  should  be  wheeled  onto  the  sleeping  porch,  thus  obviating 
the  disadvantageous  conditions  mentioned  above. 

Figs.  81  and  82  show  the  plan  of  a  sleeping  porch,  designed  and 
constructed  by  Dr.  D.  C.  Hall.  An  opening  is  made  in  the  wall  large 
enough  for  the  bed  to  roll  through  onto  the  porch.  The  head  and 
foot  boards  are  so  constructed  that  the  opening  in  the  wall  is  entirely 


488  OPEN-AIR   TREATMENT 

closed  when  the  bed  is  at  full  length  on  the  porch  or  in  the  room. 
The  room  is  thus  kept  warm  for  dressing  in  the  morning.  The  bed 
is  supported  by  four  large  roller  bearing  wheels,  one  hand  of  a  child 
sufficing  to  move  it  out  or  in.  Grips  are  so  arranged  that  the  bed  can 
be  drawn  out  or  in,  while  the  occupant  is  in  the  reclining  position. 

Open-air  Treatment  of  Febrile  Patients. — The  afebrile  patient  may 
indulge  in  driving,  automobiling,  or  sleighing  during  the  winter,  but 
always  within  the  limits  set  by  the  physician. 

He  should  discard  many  of  the  pleasures  of  healthy  people,  even 
when  he  thinks  he  is  well;  he  should  not  visit  theatres,  balls,  crowded 
restaurants,  etc.,  where  large  numbers  of  persons  congregate  and 
contaminate  the  air.  Many  a  patient  who  has  been  doing  well,  and 
was  on  the  road  to  recovery,  has  suffered  a  relapse  or  a  complication, 
after  attending  a  function  at  which  a  large  number  of  persons  got 
together  in  a  confined  space. 

With  febrile  cases  things  are  not  so  simple.  They  must  remain 
in  bed  as  long  as  the  fever  lasts,  excepting  under  circumstances 
which  are  discussed  elsewhere.  In  the  city  the  bed  can  only  be  kept 
within  the  room  and  for  this  reason,  as  well  as  for  others,  it  must  be 
placed  near  the  window,  so  that  not  only  pure,  fresh  air  may  be  avail- 
able at  all  times,  but  also  because  the  patient  is  usually  encouraged 
looking  out  at  the  living  world.  In  the  suburbs  the  bed  may  be 
placed  on  the  porch  during  the  day,  and  under  certain  circumstances 
it  may  remain  there  all  the  time.  When  feasible,  a  proper  tent  or  porch 
is  even  better.  Placing  tents  on  roofs  of  houses  in  the  city,  or  modifying 
fire  escapes  so  that  the  patient  may  be  kept  on  them  in  the  open  air, 
are  not  feasible.  No  patient  wishes  to  expose  himself  to  the  curious- 
gaze  and  commiseration  of  the  other  inhabitants  of  the  house,  as  was 
already  mentioned. 

The  good  effects  of  the  open-air  treatment  are  very  striking  in  febrile 
cases.  The  general  condition  of  the  patient  improves,  a  feeling  of 
well-being  ensues,  replacing  the  despondency  into  which  he  was 
sinking.  His  strength  returns.  The  anorexia  and  indigestion  which 
sapped  his  strength  disappear,  or  are  ameliorated,  and  he  eats  with  a 
better  appetite.  The  painful  cough  often  disappears  within  a  few 
days  and  nights  with  open  windows  or  on  the  porch.  This  is  at  times 
the  most  salutary  phenomenon ;  sometimes  when  sedatives  have  failed 
to  control  the  cough,  outdoor  life  works  in  this  direction  and  the  efl^ect 
on  the  morale  of  the  patient  is  marvellous. 

We  often  have  patients  who,  in  mortal  fear  of  "colds,"  decline  to 
carry  out  the  open-air  treatment;  their  relatives  and  friends  discour- 
age them  yet  more.  But  several  days'  experience  along  the  line  just 
described  convinces  the  average  patient.  At  the  Montefiore  Hospital, 
where  the  patients  come  from  the  tenement  districts  of  New  York 
City,  and  have  always  feared  open  windows,  they  soon  find  out  the 
advantages  of  fresh  air  and  would  strongly  resent  any  attempts  at 
closing  the  windows.    It  is  often  necessary  to  control  the  "fresh-air 


TECH  NIC  OF  TREATMENT  489 

fiends,"  when  conditions  arise  which  necessitate  their  remaining 
indoors  for  some  time. 

The  superstitious  fear  for  colds  and  draughts  is  one  of  the  greatest 
drawbacks  in  phthisiotherapy.  The  patients  are  apt  to  ascribe  all 
their  troubles  to  colds.  After  passing  through  an  acute  exacerbation 
of  the  disease,  which  they  usually  ascribe  to  a  cold;  or  getting  some 
pain  or  ache  in  the  chest,  or  hoarseness  due  to  laryngeal  complication, 
etc.,  they  begin  to  fear  exposure.  This  is  to  be  discouraged.  The 
patient  is  to  be  told  clearly  and  distinctly  that  his  troubles  are  not 
due  to  fresh  air,  but  to  the  lack  of  it,  and  that  a  cure  can  only  be 
attained  by  living  outdoors. 

During  the  night  the  open-air  treatment  is  just  as  simple  as  during 
the  day.  It  consists  in  one  simple  principle — open  windows.  They 
must  be  opened  completely;  the  upper  half  must  be  completely 
lowered  and  the  opening  should  not  be  obstructed  by  any  shade  or 
curtain.  Patients  who  have  not  slept  in  a  well-ventilated  room — the 
fact  that  they  are  phthisical  shows  that  they  have  not — and  are  not 
habituated  to  cold  air  during  the  night,  rebel  when  told  to  open  their 
windows  widely  during  winter  nights,  but  a  trial  of  a  few  nights  con- 
vinces most  of  the  sceptics. 

With  obstinate  patients  we  may  begin  by  lowering  the  windows  one- 
third;  after  a  few  nights  the  opening  is  increased  to  one-half,  etc., 
so  that  within  a  week  or  two  the  patient  finds  out  that  sleeping  with 
a  free  current  of  air  invigorates  him  and  he  will  not  tolerate  their 
closure. 

Half-measures,  such  as  opening  the  windows  in  adjoining  rooms, 
etc.,  are  not  to  be  tolerated.  The  patient  should  be  impressed  with  the 
fact  that  it  is  not  only  fresh  air  we  are  looking  for,  but  a  free  circulation 
of  it  and  this  can  only  be  attained  by  keeping  the  windows  open  in 
the  room  he  inhabits. 

As  a  rule,  there  is  no  necessity  for  heating  the  sleeping  room  for  the 
night  during  the  greater  part  of  the  winter.  Warm  sleeping  rooms  are 
badly  ventilated.  Only  during  the  very  cold  days  is  there  a  necessity 
for  heat,  but  the  windows  must  remain  open.  Careful  measurement 
has  shown  that  the  temperature  within  the  room  is  always  above 
that  outside  and  the  humidity  is  lower.  A  suflScient  number  of 
blankets  and  plenty  of  flannel  underwear,  used  according  to  the 
temperature,  will  keep  any  patient  warm.  The  fear  entertained  by 
many  patients  that  exposure  of  a  limb  in  a  cold  room  may  be  harmful 
is  not  supported  by  facts  observed  in  daily  practice.  The  human 
being  keeps  its  limbs  instinctively  covered  when  sleeping  in  a  cold 
room.  Moreover,  insomnia  is  sure  to  occur  if  he  is  not  well  covered. 
It  is  also  a  fact  that  persons  lying  in  bed  well  covered  feel  quite  warm 
in  a  room  so  cold  that  those  around  find  it  difficult  to  bear,  as  is  the 
experience  of  nurses  attending  to  outdoor  patients. 

It  is  self-understood  that  very  few  patients  will  at  once  begin  the 
treatment  by  undressing  in  a  cold  room  during  the  winter  and  going  to 


490  OPEN-AIR   TREATMENT 

bed  and  again  dressing  in  the  morning  in  a  cold  room.  For  this  reason 
it  is  much  easier  to  institute  the  treatment  during  the  summer.  But 
in  winter  we  may  begin  by  warming  the  room  an  hour  or  so  before  the 
patient  is  expected  to  retire  and  again  before  he  rises  in  the  morning. 
But  in  time  many  patients  discover  that  all  this  is  unnecessary  and  they 
undress  and  dress  in  a  cold  room  without  a  murmur.  In  many  cases 
the  patients  prefer  to  have  an  adjoining  room  for  this  purpose. 

Wind,  rain,  and  snow  are  not  sufficient  reason  for  closing  the  win- 
dows of  the  sleeping  room  of  the  patient.  This  must  be  insisted  upon 
and  the  patient  should  be  convincingly  told  that  it  is  the  fresh,  circulat- 
ing air  which  replaces  his  expired  air  and  cools  his  body  that  keeps  up 
his  vitality.  Even  during  complications  of  phthisis  the  windows  are 
not  to  be  closed  in  the  vast  majority  of  cases;  most  of  these  are  pre- 
vented or  cured  by  fresh,  cold  air. 

In  moderate  climates  consumptives  feel  better  during  the  winter, 
as  was  already  shown  when  discussing  hemoptysis,  emaciation,  etc. 
It  is  the  universal  experience  that  when  the  summer  heat  is  accom- 
panied by  excessive  humidity  tuberculous  patients  suffer  from  anorexia, 
insomnia,  general  weakness,  etc.,  and  they  often  lose  the  greater  part 
of  what  they  have  gained  during  the  cold  winter.  For  this  reason 
I  insist  that  all  patients  under  home  treatment  should  leave  at  least 
for  the  two  months  of  July  and  August  for  the  mountains.  It  is  also 
well  that  during  warm  days  an  electric  fan  should  be  installed  in  the 
rooms  inhabited  by  consumptives  for  reasons  already  made  clear. 

Results  Attained  by  Open-air  Treatment. — The  results  attained  by 
the  open-air  treatment  depend  on  many  conditions,  notably  the  acute- 
ness  and  the  stage  of  the  disease.  In  acute,  progressive  cases  we  cannot 
expect  much  more  than  from  any  other  method  of  treatment,  except- 
ing perhaps  more  comfort  to  the  patient  than  would  be  the  case  if 
he  were  kept  indoors.  The  ultimate  prognosis  is  gloomy  at  all  events. 
In  fact,  if  these  patients  insist  that  they  cannot  bear  the  cold,  it  is 
of  no  use  arguing  with  them;  it  is  best  to  let  them  have  their  own 
way  during  their  last  earthly  days.  In  subacute  cases  the  process  is 
at  times  arrested  and  the  disease  then  pursues  the  course  of  chronic 
phthisis. 

The  good  effects  of  the  open-air  treatment  are  best  seen  in  the 
average  case  of  incipient  chronic  phthisis  which  begins  with  moderate 
fever,  nightsweats,  anorexia,  cough,  etc.  In  advanced  cases  of  the 
disease,  when  the  patient  is  emaciated  and  apparently  hopeless,  several 
days  of  life  in  the  open  air  often  transform  a  despondent  individual 
into  one  who  shows  his  confidence  in  ultimate  recovery  very  clearly. 
He  gains  in  courage  and  a  desire  for  recovery ;  his  fever  declines,  the 
nightsweats  disappear,  the  cough  and  expectoration  diminish,  and  he 
becomes  hopeful  in  general. 

In  the  far-advanced  stages  of  the  disease  the  open-air  treatment 
may  only  render  the  last  days  of  life  somewhat  more  bearable,  contrib- 
ute to  the  false  optimism  which  is  often  seen  in  these  patients,  and 


CONTRA-INDICATWNS  491 

accentuate  the  euphoria  which  has  been  considered  characteristic  of 
the  disease.  But  it  is  undoubtedly  curative  in  the  vast  majority  of 
incipient  cases.  The  entire  aspect  of  the  patient  is  often  transformed 
within  a  week  or  two,  and  the  improvement  is  usually  progressive. 
A  good  appetite  and  assimilation  and  digestion  of  the  food,  disappear- 
ance of  the  fever,  nightsweats,  insomnia,  and  amelioration  of  the  cough, 
are  the  rule  in  these  cases.  Often  it  will  be  noted  that  fever  which 
resisted  all  other  treatment  for  months  disappears  after  several  days 
of  life  with  open  windows  during  day  and  night.  Many  patients 
learn  it  by  experience  and  cannot  be  induced  to  close  the  windows. 
They  have  found  that  with  open  windows  they  sleep  better  and  feel 
refreshed  in  the  morning,  while  closed  windows  induce  cough,  night- 
sweats,  insomnia,  listlessness,  etc. 

Contra-indications. — It  must  be  emphasized  that  there  are  but  few 
contra-indications  to  the  open-air  treatment.  Even  hemoptysis, 
however  severe,  should  not  induce  us  to  close  the  windows  of  the  room 
inhabited  by  a  tuberculous  patient.  Nor  should  they  be  closed  during 
any  season,  as  was  already  mentioned.  Only  during  the  summer, 
when  the  external  air  is  often  hot  and  humid,  and  even  open  windows 
are  not  effective  in  producing  a  free  circulation  of  the  air  within  the 
room,  this  method  is  often  futile.  An  electric  fan  may  improve  con- 
ditions somewhat,  but  it  is  best  that  patients  who  can  afford  it  should 
leave  the  city  for  a  milder  or  colder  region. 

There  is  a  small  number  of  patients  who  do  not  bear  the  open-air 
treatment  very  well  during  the  winter  months;  in  fact  in  some  it  is 
distinctly  harmful,  and  if  an  attempt  is  made  to  apply  it,  it  must  be 
done  with  great  care  and  circumspection.  Patients  who  suffer  from 
diffuse  bronchitis  in  addition  to  phthisis  do  not  bear  cold  air  very 
well  and  so-called  "rheumatic  pains"  in  the  joints  are  often  aggra- 
vated by  sleeping  in  a  cold  room.  Cold  air  is  also  bad  for  consumptives 
who  suffer  from  organic  heart  disease — dyspnea  and  the  cough  are 
decidedly  provoked  by  winds,  draughts,  and  cold  air  in  general.  Those 
suffering  from  profound  anemia  at  times  cannot  be  kept  warm  by  any 
means  in  a  cold  room.  Some  nervous  patients  who  have  obstinately 
made  up  their  minds  that  the  cold  is  harmful  are  also  bad  material 
for  this  mode  of  treatment.  The  same  is  true  of  old  persolis  w^ith  bad 
peripheral  circulation,  and  extremely  cachectic  patients — they  cannot 
be  kept  comfortable  in  cold  rooms  during  winter  nights. 

In  all  these  cases  it  is  necessary  to  heat  the  room,  but  the  windows 
should  under  no  condition  be  closed  completely.  On  the  other  hand, 
when  some  complication  ensues,  such  as  influenza,  pleurisy,  pneumonia, 
etc.,  there  is  no  necessity  for  closing  the  windows.  These  conditions 
are  also  benefited  by  fresh,  cold  air. 


CHAPTER  XXXIII. 
CLIMATIC  TREATMENT. 

We  have  seen  that  the  vast  majority  of  tuberculous  patients  are 
amenable  to  home  treatment;  if  they  are  to  recover  at  all,  they  can 
accomplish  it  without  leaving  their  home  surroundings.  The  autopsy 
findings  showing  that  many  persons  have  healed  tuberculous  lesions 
in  the  lungs  and  pleura  although  they  have  never  undergone  a  course 
of  institutional  or  climatic  treatment,  prove  clearly  that  tuberculosis 
is  curable  in  all  climates.  But  there  are  undoubtedly  indications  for 
certain  forms  of  climatic  treatment  in  tuberculosis,  though  they  are 
not  as  imperative,  nor  as  necessary  for  the  average  case  as  the  laity 
and  part  of  the  profession  believe.  In  this  chapter  we  shall  attempt 
to  review  the  indications,  and  point  out  the  limitations  of  climatic 
treatment. 

Climatic  treatment  of  tuberculosis  is  probably  older  than  any  other 
method  which  has  survived  the  recent  advent  of  scientific  medicine. 
The  ancient  Greek  and  Roman,  as  well  as  the  medieval  Arabic  physi- 
cians were  great  believers  in  the  efficacy  of  certain  climates  in  the 
control  and  treatment  of  phthisis.  The  first  thought  that  enters  the 
mind  of  the  average  modern  physician  after  diagnosticating  a  case  of 
tuberculosis  is  "Where  should  I  send  the  patient?"  If  the  physician 
is  negligent  in  this  regard,  the  patient  will  surely  ask  him  "Must  I 
leave  the  city?" 

It  is,  however,  a  fact  agreed  to  by  all  entitled  to  an  opinion  that 
recent  studies  of  the  effects  of  various  climates  on  the  incidence  and 
the  course  of  phthisis  have  not  resulted  in  discovering  a  region  on  the 
habitable  globe  which  can  be  relied  on  to  cure  or  improve  all  incipient 
or  a  substantial  proportion  of  advanced  cases  of  the  disease.  When- 
ever geographical,  topographical,  meteorological  and  clinical  data  are 
correlated -with  demographic  data  for  a  given  locality,  and  conclusions 
drawn  that  a  very  high  percentage  of  cases  recover  when  sent  there, 
there  are  at  once  shown  other  facts  which  prove  conclusivel}'  that 
under  climatic  conditions  diametrically  opposed  to  these,  the  propor- 
tion of  recoveries  is  about  the  same.  For  these  reasons  many  physi- 
cians have  gone  to  the  opposite  extreme  and  claim  that  climate  need 
not  at  all  be  considered  as  a  therapeutic  agent  in  the  control  and  cure 
of  phthisis. 

Economic  Aspects  of  Climatic  Treatment. — Other  reasons  militating 
against  the  extensive  utilization  of  certain  climates  may  be  mentioned. 
Bearing  in  mind  that  the  bulk  of  consumptives  are  recruited  from  the 
poorer  strata  of  society  and  that  even  those  who  had  been  self-sup- 


COST  OF  CLIMATIC   TREATMENT  493 

porting  before  they  were  attacked  by  the  disease  often  become  depen- 
dent soon  after  that  event,  it  is  evident  that  the  economic  factor  is 
to  be  given  great  weight  in  this  connection.  Indeed,  chmatic  treat- 
ment is  as  expensive  as  institutional  treatment;  it  is  even  more 
beyond  the  reach  of  most  patients  because  modern  municipahties 
provide,  as  a  rule,  institutions  for  the  tuberculous,  but  hardly  any 
supply  funds  with  which  patients  may  go  to  distant  parts  of  the  country 
and  support  themselves  for  a  considerable  time. 

This  economic  aspect  of  climatic  treatment  is  too  often  disregarded 
b}^  physicians  who  tell  their  patients,  irrespective  of  their  financial 
condition,  to  go  to  distant  regions.  Those  who  cannot  raise  the  funds 
and  must  stay  at  home  become  despondent  and  the  prognosis  is  often 
aggravated  as  a  result  of  it.  Some  of  them  go  with  meagre  funds  to 
Colorado,  Arizona,  California,  etc.,  and  the  result  is  even  more  dis- 
astrous. Very  few  physicians  heed  the  warnings  of  experienced  men 
like  E.  S.  Bullock,^  who  says:  "I  must  emphatically  maintain  that  no 
consumptive  should  ever  be  sent  away  if  it  is  not  certain  that  he  will 
have  as  good  care  and  management  in  the  distant  climate  as  he  could 
obtain  near  home." 

Cost  of  Climatic  Treatment. — Thompson  Fraser,'-^  who  has  made  a 
study  of  this  problem  in  Asheville,  N.  C,  and  reported  his  observations 
in  the  Public  Health  Reports,  shows  that  it  must  always  be  borne  in 
mind  that  there  is  a  clear  relation  between  income  and  recovery  in 
tuberculosis.  When  leaving  for  some  climatic  region,  the  patient 
must  be  prepared  to  provide  himself  with  the  proper  requisites.  If 
he  lacks  funds  he  should  not  undertake  a  trip  which  not  only  exhausts 
his  resources,  but  does  him  no  good;  he  should  rather  stay  at  home. 
He  points  out  that  at  Asheville,  and  this  holds  good  for  nearly  every 
other  climatic  resort  in  this  country,  the  expense  is  about  as  follows: 

The  cost  of  room  and  board  varies  within  wide  limits.  From  his 
observations  at  Asheville,  board  of  fair  quality  with  room  costs  from 
$10toS12a  week  at  the  houses  which  are  licensed  to  take  tuberculous 
patients.  The  price  depends  to  some  extent  on  the  location  of  the 
rooms,  the  more  desirable  ones  costing  more,  while  less  desirable  rooms 
may  be  had  for  $8.  The  "extras,"  Fraser  points  out,  amount  to 
almost  as  much  as  the  cost  of  the  room  and  board,  including,  as  they 
do,  additional  food,  milk,  eggs,  reclining  chair,  physicians'  fees,  medi- 
cines, thermometers,  blankets  for  cold  weather,  laundry,  and  every- 
thing that  comes  under  the  item  of  "incidentals." 

Fraser's  conclusions  are  that  the  cost  to  the  patient  for  a  period 
of  ten  months,  or  forty-three  weeks,  at  .$8,  SIO,  $12  a  week  would  be 
$344,  $430,  $516,  respectively,  not  including  the  extras,  just  men- 
tioned. A  minimum  of  $700,  therefore,  exclusive  of  carefare,  would 
be  a  more  just  estimate  of  the  expense  for  the  rather  arbitrary  period 
of  ten  months.    If  the  patient  is  accompanied  by  some  member  of  the 

1  Jour.  Amer.  Med.  Assn.,  1909,  lii,  1973. 

2  Public  Health  Reports,  September  18,  1914,  xxix. 


494  CLIMATIC   TREATMENT 

family,  it  may  be  decided  to  keep  house  instead  of  to  board,  but  this  " 
will  not  prove  more  economical  in  most  cases. 

The  estimate  for  room,  board,  and  treatment  for  a  period  of  ten 
months  applies  especially  to  those  cases  which  can  be  benefited  by  a 
comparatively  brief  stay.  If  the  disease  has  made  greater  inroads, 
and  a  longer  stay  is  necessary  to  produce  results,  the  cost  of  extras 
and  perhaps  of  nursing  may  be  prohibitive  to  the  average  consumptive 
and  it  is  wiser  to  remain  at  home  where  suitable  food,  care,  and  com- 
forts will  more  than  outweigh  the  benefits  of  climactic  factors  if 
unassisted  b}'  these  essentials. 

Climatic  treatment  is  thus  a  luxury  available  for  the  chosen  few, 
while  the  vast  majority  of  sufferers  from  tuberculosis  must  perforce 
remain  in  their  homes  for  treatment. 

Effects  of  Change  of  Enviroiiment. — Looking  with  a  sane  and 
unbiased  view  on  the  problems  of  climaiic  treatment  of  phthisis,  we 
find  that  it  is  undoubtedly  an  important  adjuvant  to  our  efforts  at 
curing  our  patients.  Even  physicians  who  practise  in  cities  and  have 
good  results  with  home  treatment  are  often  impressed  with  the  salu- 
tary effects  of  a  change  of  surroundings.  One  has  but  to  note  the 
effects  on  a  patient  who  has  been  kept  at  home  for  several  months, 
and  all  available  hygienic,  dietetic,  and  therapeutic  measures  to  control 
the  disease  have  been  taken,  yet  the  patient  has  been  going  steadily 
downward.  A  change  in  surroundings  is  decided  upon  and  he  is  sent 
out  to  the  country,  preferably  a  place  the  patient  selects,  provided 
there  are  no  strong  objections  to  it.  It  makes  no  difference  whether 
the  locality  selected  is  at  the  sea  coast  or  inland,  in  a  forest  or  a  desert, 
on  a  high  altitude  or  the  plains;  it  is  immaterial  whether  the  number 
of  sunny  days  calculated  by  the  weather  man  or  by  the  owner  of  the 
resort  in  the  neighborhood,  is  small  or  large,  whether  it  is  foggy,  or 
even  frequently  rainy — the  results  are  often  astonishing.  After  re- 
maining there  for  a  few  months,  the  patient  returns  greatly  improved, 
in  some  cases  even  apparently  cured.  These  are  the  facts  which  every 
observing  physician  is  bound  to  meet  in  his  daily  practice  and  cannot 
be  controverted  by  statistics  or  opinions  of  famous  clinicians.  But  it 
is  clear  that  in  such  cases  it  is  not  the  meteorological  or  topographical 
conditions  which  are  altogether  responsible  for  the  good  results 
attained  by  the  change. 

Carefully  analyzing  the  results  obtained  by  patients  under  my 
observation,  I  have  arrived  at  the  conclusion  that  the  complex  phe- 
nomena grouped  under  the  title  "change  of  environment,"  or  the  ps^'chic 
and  biological  response  of  the  organism  to  a  change  in  surroundings, 
play  here  a  greater  role  than  the  difference  in  the  composition  and 
density  of  the  air,  or  the  number  of  sunny  and  foggy  days.  The  change 
in  environment  acts  as  a  new  stimulus,  reinvigorates  and  calls  forth 
the  dormant  vital  forces  of  the  patient. 

Suggestion  is  a  factor  in  climatic  treatment  of  tuberculosis  which 
has  not  been  gi\en  the  credit  it  deserves.    The  patient  has  heard  that 


EFFECTS  OF  CHANGE  OF  ENVIRONMENT  495 

a  consumptive  cannot  recover  in  the  city,  and,  when  unable  to  leave 
for  any  reason  for  some  place  reputed  to  be  efficacious  in  this  direction, 
he  becomes  despondent.  Many  brood  over  it  to  an  extent  as  to  negate 
all  other  therapeutic  measures.  Once  they  are  sent  away,  all  potential 
and  inherent  vital  forces  are  stimulated;  despondency  is  replaced  by 
a  feeling  of  hopefulness,  accompanied  by  an  increase  in  the  appetite, 
improved  assimilation  of  food,  diminution  in  the  cough,  etc.  This  is 
proven  by  the  following  facts  which  have  come  under  our  observation : 

Patients  leave  their  homes  where  they  have  been  under  the  tender 
care  of  relatives  and  have  had  good  and  properly  prepared  food,  to  the 
mountains  or  the  sea  coast  where  they  are  compelled  to  live  in  cheap 
boarding  houses  or  hotels,  in  which  the  food  given  them  is  far  inferior 
to  that  which  they  had  been  getting  at  home.  Yet  they  thrive  and  gain 
in  weight,  while  at  home  they  had  been  wasting  progressively.  Others 
go  to  hotels  and  boarding  houses  which,  for  obvious  reasons,  allege  in 
their  advertisements  that  the  in  reality  much-coveted  consumptives 
are  barred.  In  fear  that  when  coughing  the  proprietor  of  the  hostelry 
is  liable  to  discover  their  ailment,  the  patients  promptly  cease  cough- 
ing. In  many  cases  the  gain  is  only  temporary  and  after  the  so-called 
acclimatization,  the  "climate  wears  out."  Brown^  says  that  it  is  rarely 
advisable  for  a  patient  to  remain  in  any  climate  without  change  for 
more  than  eight  or  nine  months.  But  the  gain  is  immense  in  a  large 
proportion  of  cases.  The  disease  often  takes  a  turn  to  the  better, 
or  the  patient  is  carried  over  an  acute  exacerbation  and  given  an 
opportunity  to  recover  his  inherent  vital  forces. 

This  effect  of  a  change  of  environment  is  often  seen  in  patients, 
themselves  natives  or  residents  of  agricultural  districts,  even  high 
mountainous  regions,  who  have  become  sick  with  tuberculosis,  and 
coming  to  the  city  to  consult  a  physician  improve  in  spite  of  the  fact 
that  climatic  conditions  are  undoubtedly  inferior.  But  there  was  a 
change  of  environment. 

That  it  is  not  entirely  the  climate  yer  se  which  is  responsible  in  all 
cases  which  improve  by  a  change,  is  acknowledged  by  most  authori- 
ties on  medical  climatology.  Henry  SewalP  points  out  an  antagonism 
between  the  vital  effects  immediately  attendant  on  a  change  of  climate 
and  those,  often  totally  different  in  character,  which  may  develop 
during  permanent  residence.  "In  short,  a  change  of  scene,  irrespective 
of  the  character  of  the  environment,  has  often  temporarily  a  myste- 
rious influence  for  good  on  the  living  organism.  The  first  vital  reactions 
to  new  climatic  conditions  involve  especially  the  nervous  system,  the 
final  eftects  are  dependent  on  the  modified  metabolism  of  the  individ- 
ual organs,  and  this  may  or  may  not  be  conductive  to  the  efficiency  of 
the  body  as  a  whole."  Brown  puts  it  pointedly  when  he  says  that 
without  doubt  many  of  the  effects  attributed  to  climate  can  be  ascribed 
to  change  of  climate. 

1  Osier's  Modern  Medicine,  i,  488. 

2  Klebs'  Tuberculosis,  p.  664. 


496  CLIMATIC   TREATMENT 

The  writer  has  observed  patients  who  left  a  favorable  climate  where 
they  have  done  badly,  for  an  unfavorable  one,  where  they  soon  improve 
wonderfully.  Many  immigrants  who  become  tuberculous  in  New  York 
City,  try  institutional  treatment  and  fail  to  improve.  A  longing  for 
their  native  land  overtakes  them  and  they  return  home  where  they 
remain  for  some  months  and  return  to  this  country  cured.  We  have 
observed  numerous  instances  of  this  kind  in  New  York.  From  personal 
observations,  the  writer  can  testify  that  the  hygienic,  sanitary,  eco- 
nomic, and  social  conditions  in  southern  Italy,  Hungary,  Russia,  and 
Poland,  where  these  patients  go,  are  inferior  to  those  in  which  they 
live  in  New  York.  Indeed,  tuberculosis  in  those  countries  is  more 
ravaging  than  here;  is  more  often  fatal.  Nor  are  there  sufficient 
accommodations  for  dependent  consumptives.  Still,  many  immigrant 
patients,  who  fail  to  get  relief  in  the  many  excellent  public  sanato- 
riums  in  this  country,  in  the  mountainous  regions  of  Colorado,  Arizona, 
or  the  beautiful  parts  of  Southern  California,  go  to  some  large  or  small 
city  in  southern  or  eastern  Europe  and,  after  remaining  there  for 
several  months,  return  apparently  cured  and  able  to  work. 

There  is  no  doubt  that  in  such  cases  it  is  not  the  climatic  conditions 
that  helped,  but  the  confidence  they  placed  in  their  native  lands,  in 
the  home  surroundings,  in  the  caressing  tenderness  of  loving  relatives, 
etc.,  which  was  instrumental  in  awakening  the  reparative  forces  of  the 
organism. 

There  are  other  reasons  for  sending  patients,  who  can  afford  to  go, 
to  some  region  with  a  favorable  climate.  It  is  very  often  difficult  to 
enjoin  complete  rest  and  freedom  from  the  worries  and  anxieties  of 
every  day  life  in  the  home  of  the  patient.  Nor  can  he  be  kept  from  the 
temptations  of  city  life.  These  objects  may  be  accomplished  by  remov- 
ing him  from  his  home  environment  into  some  secluded  country  place. 
The  patient  is  to  be  told  that  he  will  have  to  remain  away  from  home 
for  several  months  and  he  should  not  leave  unless  he  has  sufficient 
funds  for  the  purpose.  His  relatives  are  to  be  warned  against  inform- 
ing the  patient  of  any  troubles  at  home.  To  this  must  be  added  the 
regular  hours  for  meals,  rest,  exercise,  etc.,  which  are  followed  implic- 
itly in  the  country,  but  often  disregarded  in  the  city  with  its  tempta- 
tions. I  have  had  results  which  were  astonishing  with  patients  sent 
away  in  this  manner. 

With  some  patients  institutional  treatment  is  best  for  these  reasons, 
as  will  be  shown  later  on,  while  with  others  the  reverse  is  true.  In 
fact,  many  patients  are  better  off  when  sent  out  into  the  country, 
than  when  sent  to  closed  institutions. 

Where  to  Send  Patients. — Experience  has  shown  that  for  the  vast 
majority  of  cases  of  incipient  and  uncomplicated  phthisis  it  makes  little 
difference  whether  they  go  to  a  mountainous  region  or  to  lowland,  to 
the  sea  coast  or  inland,  to  a  moderate  or  cold  region;  the  effect  is 
practically  the  same,  as  long  as  they  are  taken  away  from  their  homes 
and  placed  under  favorable  surroundings  away  from  the  troubles  of 


MOUNTAIN  CLIMATES  497 

home  life.  There  is  no  chmate  which  cures  consumption,  the  many 
laudatory  advertisements  of  institutions  and  railroad  companies  not- 
withstanding. The  fact  that  nearly  all  successful  sanatoriums,  located 
as  they  have  been  in  such  a  diversity  of  climatic  environments,  show 
practically  the  same  proportion  of  cured,  arrested,  improved  and  last 
but  always  least,  dead,  proves  conclusively  that  if  the  climatic  con- 
ditions are  a  factor,  they  are  of  least  importance. 

A  careful  perusal  of  Guy  Hinsdale's  prize  essay  on  Atmospheric 
Air  in  Relation  to  Tuberculosis,  which  is  one  of  the  best  books  on  the 
subject,  and  most  impartial  because  the  author  is  not  anxious  to  boost 
some  region  or  institution,  shows  clearly  that  climate  is  of  little  thera- 
peutic importance  in  tuberculosis.  He  admits  that  good  results  are 
obtained  in  cloudy  regions,  as,  for  instance,  in  the  Adirondacks,  and 
at  Rutland,  Mass.  He  has  no  objection  to  sunshine  because  the 
moral  effects  of  bright  sunny  days  and  plenty  of  them  are  very  great. 
As  to  the  question  of  temperature  and  humidity,  Hinsdale  concludes 
that  the  majority  of  incipient  cases  do  best  in  dry  and  cool  places 
"not  warm  enough  to  be  relaxing,  but  not  so  cold  as  to  be  repellant 
and  restrict  exercise  and  out-of-door  life."  The  old  ideas  about 
equability  of  temperature,  at  least  between  the  temperature  of  mid- 
day and  midnight,  are  not  of  great  importance;  all  mountainous  stations 
show  great  variations  in  this  respect.  Some  variability  tends  to  stim- 
ulate the  vital  activities,  but  in  older  people  and  those  who  are  feeble, 
great  variability  is  a  disadvantage.  Hinsdale  denies  that  altitude 
yer  se  has  any  great  influence.  It  is  of  benefit  mainly  because  it  is 
incidentally  associated  with  mountain  life,  with  more  sun,  less  moisture 
and  scattered  population.  One  statement  made  by  this  author  should 
be  reprinted  with  heavy  type  in  all  discussions  on  the  subject.  "That 
a  place  is  frequented  by  consumptives  does  not  prove  that  it  is  a 
desirable  place  for  them." 

Mountain  Climates. — When  a  change  has  been  decided  upon,  the 
first  thought  which  enters  the  mind  of  the  patient,  as, well  as  that  of 
the  ph}'sician,  is  whether  a  high  altitude  is  best.  High  climates  have 
been  popular  for  centuries;  even  ancient  physicians,  who  believed  that 
phthisis  is  invariably  fatal,  sent  their  patients  to  the  mountains  when 
feasible.  Most  of  the  modern  sanatoriums  are  located  in  regions  of 
high  altitude. 

We  do  not  know  why  high  climates  are  beneficial  for  consumptives. 
Various  hypotheses  have  been  formulated  to  explain  it,  but  none  have 
been  proven.  The  purity  of  the  air  is  beyond  question;  the  absence 
of  massed  population  assures  freedom  from  air  contamination.  Humid- 
ity is  also  less  frequent,  though  not  as  rare  as  some  would  lead  us  to 
believe  and  many  sanatoriums  are  located  in  regions  which  are  notor- 
ious in  this  regard.  The  air  is  cool,  even  during  the  summer,  especially 
in  regions  of  4000  feet  or  more  above  sea  level.  But  the  cold  is  not  felt 
as  acutely  even  during  the  winter  owing  to  the  greater  diathermancy. 
The  ozone,  of  which  many  writers  of  past  generations  spoke  so  much, 
32 


498  CLIMATIC   TREATMENT 

has  been  found  to  be  worthless.  There  is  very  httle  ozone,  and  even 
if  there  were  more  we  do  not  know  that  it  would  do  much  good  to  the 
patients. 

The  diminished  atmospheric  pressure  and  rarified  air  has  been  con- 
sidered beneficial  by  increasing  the  mobility  and  expansibility  of  the 
thorax.  It  promotes  deeper,  fuller,  and  more  frequent  respiration. 
But  how  much  of  this  is  due  to  the  outdoor  life,  and  whether  outdoor 
life  at  lower  altitudes  has  not  a  similar  effect  on  consumptives,  has 
never  been  satisfactorily  investigated. 

The  effects  of  high  altitude  on  the  hematopoietic  organs  and  tissues 
have  been  investigated  and  some  have  found  an  increase  in  the  amount 
of  hemoglobin,  others,  a  polycythemia,  still  others  an  increase  in  the 
number  of  leukocytes,  etc.  Webb  and  Williams"^  have  found  an 
increase  in  the  lymphocyte  or  mononuclear  element  of  the  blood  as 
an  effect  of  high  altitude.  Some  authors,  notably  Bartel,  Bergel, 
Marie,  and  Fliessinger,  have  seen  in  this  increased  lymphocytosis  in 
tuberculosis  a  defensive  attempt  on  the  part  of  these  blood  cells,  while 
others  see  in  it  a  demonstration  that  the  lymphocytes  contain  a 
lipolytic  ferment  which  destroys  the  waxy  coat  of  the  tubercle  bacillus. 
Minnie  E.  Staines,  T.  L.  James  and  Carolyn  Rosenberg^  confirmed 
these  findings  in  Colorado.  They  found  that  at  an  elevation  of  6000 
feet  the  larger  lymphocytes  are  absolutely  increased  in  the  circulating 
blood  by  at  least  20  or  30  per  cent,  in  both  man  and  monkeys.  Webb, 
Gilbert  and  Havens^  found  an  increase  in  the  blood  platelets  in  tuber- 
culous human  beings  and  monkeys  and  that  at  high  altitudes  the 
increase  is  even  more  pronounced.  But  that  these  blood  platelets 
contain  or  supply  opsonins,  or  that  they  play  a  role  in  the  cure  of 
tuberculosis  has  not  been  proved.  On  the  whole,  it  appears  that 
the  hematologic  studies  of  phthisical  subjects  are  contradictory,  and 
it  has  been  shown  that  the  conflicting  findings  have  been  due  in  a 
great  measure  to  errors  in  technic.  It  may  be  stated  that  the  hypo- 
theses promulgated  by  some  authors  have  not  been  confirmed  by  facts 
observed  by  other  investigators. 

Some  have  maintained  that  the  proliferation  of  connective  tissue 
in  the  lungs,  the  true  reparative  process  in  phthisis,  is  enhanced  by 
a  residence  in  the  mountains.  But  von  Muralt,  who  formulated  this 
theory,  has  not  given  any  substantial  and  convincing  proof. 

Even  the  statistics  tending  to  show  that  deaths  due  to  tuberculosis 
are  less  frequent  in  mountainous  than  in  other  climates  have  not  with- 
stood scientific  tests.  It  appears  that  tuberculosis  was  rare  in  the 
Rockies,  the  Andes,  etc.,  as  long  as  the  population  was  sparse,  the 
inhabitants  leading  an  outdoor  life,  etc.  But  since  cities  have  been 
established  at  high  altitudes  and  social  conditions  favoring  the  devel- 
opment of  phthisis  created,  the  disease  is  not  infrequent  among  the 
indigenous  population. 

'  Trans.  Nat.  Assn.  Study  and  Prev.  Tuberc,  1909,  v,  2.31. 

2  Arch.  Int.  Med.,  1914,  xiv,  376.  ^  Ibid.,  1914,  xiv,  743. 


MOUNTAIN  CLIMATES  499 

It  is  thus  clear  that  economic  and  social  conditions  play  the  same 
role  in  the  cure  of  tuberculosis  in  the  mountains  as  they  do  in  the 
plains  or  at  the  sea  coast.  On  this  point  all  authors  are  agreed.  When 
a  patient  goes  to  a  high  climate,  penniless,  and  starves  there,  he  will 
succumb  just  as  quickly  as  he  does  in  the  slums  of  the  city.  If  he 
works  in  Phoenix,  Denver,  etc.,  while  the  disease  is  active,  he  may 
breathe  all.  the  rarified  air,  expand  his  chest  to  an  extreme  degree, 
and  still  succumb  just  as  quickly  as  in  the  city.  It  is  only  those  who 
can  afford  rest,  good  nourishment,  and  careful  medical  supervision 
who  are  benefited  by  life  in  a  high  altitude,  and  most  of  these  are 
also  doing  well  in  other  climates. 

Indications  for  High  Climates. — High  climates  are  no  panacea  for 
tuberculosis;  in  some  cases  they  are  not  an  unmixed  blessing.  They 
have  their  indications  and  contra-indications. 

Patients  in  whom  a  positive  diagnosis  of  active  phthisis  cannot  be 
made,  but  who  nevertheless  show  symptoms  and  signs  of  the  disease 
— in  other  words,  the  so-called  "suspects" — may  be  sent  to  the  moun- 
tains for  a  short  or  long  stay  on  the  principle  that  they  need  a  rest 
anyway.  But  we  must  be  careful  and  not  suggest  such  a  vacation  to 
those  with  limited  means.  I  have  seen  self-supporting  artisans  ruined,' 
their  children  committed  to  asylums,  while  the  father  was  sent  away 
to  the  mountains  without  a  positive  diagnosis  of  tuberculosis.  That 
they  returned  within  a  month  or  two  reinvigorated  and  in  excellent 
health,  was  not  sufficient  to  justify  the  sacrifice;  the  same  result 
could  have  been  obtained  by  less  costly  means.  It  is  different  with 
the  well-to-do,  who  mostly  court  a  vacation. 

A  large  number  of  neurotics,  anemic  and  debilitated  individuals 
who  are  in  constant  fear  of  tuberculosis,  and  in  whom  a  diagnosis 
has  been  made  by  some  physician,  but  careful  examination  fails  to 
elicit  any  symptoms  and  signs  pointing  to  a  lesion  in  the  lung,  are 
nearly  always  benefited  by  a  stay  in  the  mountains.  Phthisiophobia, 
which  may  be  considered  a  distinct  syndrome  common  in  modern 
times,  should  be  treated  in  the  mountains  when  patients  can  afford 
the  change.  They  may  remain  under  the  impression  that  they  have 
been  cured  of  tuberculosis,  but  this  does  not  make  any  material 
difference,  as  long  as  they  are  relieved. 

Many  of  these  "suspects"  and  "phthisiophobiacs"  may  have  been 
cases  of  abortive  tuberculosis  in  which  the  physical  signs  were 
indefinite  or  absent.  The  rest  in  the  mountains  and  the  change 
of  environment  undoubtedly  contribute  to  their  recovery. 

Incipient  cases  of  tuberculosis  with  few  constitutional  symptoms 
gain  considerably  by  a  change  for  a  mountainous  climate.  The  appe- 
tite improves,  the  anemia  vanishes  and  they  often  gain  in  weight 
better  than  they  would  have  in  the  city  with  its  temptations.  The 
patients  are  also  freed  from  the  troublesome  solicitations  of  their 
relatives  anfl  friends  which  are  often  more  a  detriment  than  a  help  to 
recovery. 


500  '  CLIMATIC  TREATMENT 

Active  phthisis  in  the  moderately  advanced  stage  which  does  not 
improve  under  home  treatment  for  any  reason  may  be  sent  to  the 
mountains  for  a  prolonged  stay.  It  is  at  times  surprising  to  see  marked 
improvement  manifesting  itself  soon  after  their  arrival  in  the  country. 
Fever  is  no  contra-indication,  provided  it  is  not  of  the  hectic  or  ter- 
minal variety,  or  due  to  some  complication  which  may  be  aggravated 
in  a  high  altitude.  Occasionally  a  pleural  effusion  showing  no  ten- 
dency to  absorption  will  disappear  after  a  stay  in  the  mountains.  F. 
L.  Knight  preferred  patients  of  phlegmatic  temperament  to  the 
nervous,  with  irritable  heart,  frequent  pulse  and  inability  to  resist  cold. 

Of  course  most  tuberculous  patients  who  can  afford  the  expense 
should  be  sent  to  the  country,  preferably  the  mountains,  during  the 
hot  and  humid  summer  months. 

Contra-indications. — ^As  was  already  stated,  high  climates  are  like 
a  double-edged  sword  and  may  be  harmful.  As  a  general  rule  it  may 
be  said  that  hopeless  cases,  running  an  acute  course  with  hectic  or 
high  continuous  fever,  with  a  rapid  extension  of  the  process  in  the 
lungs,  profound  emaciation,  edema  of  the  extremities,  etc.,  should 
not  be  sent,  for  obvious  reasons.  It  is  a  great  pity  to  send  them  travel- 
ling great  distances,  which  aggravates  their  already  bad  condition,  to 
suffer  or  die  among  strangers.  Their  relatives  are  also  to  be  consid- 
ered. Upon  hearing  of  the  desperate  condition  of  the  patient  on  his 
arrival  at  his  destination,  they  may  have  to  go  to  see  him. 

Some  of  these  progressive  and  apparently  hopeless  cases  take  a 
turn  to  the  better  with  careful  home  treatment;  the  fever  abates,  the 
appetite  improves,  the  strength  begins  to  return.  At  this  stage  it 
may  be  well  to  send  them  away  to  the  mountains  where  the  improve- 
ment which  began  in  the  city  is  enhanced  by  the  new  surroundings. 
At  any  rate,  they  do  not  lose  by  the  change  and,  when  they  can  afford 
it,  it  may  contribute  greatly  to  their  ultimate  recovery.  But  they 
need  experienced  nurses  to  take  care  of  them. 

Dyspnea  is  a  strong  contra-indication  to  a  mountainous  climate. 
It  is  often  not  considered  and  the  results  are  disastrous.  Consumptives 
with  dyspnea  due  to  pulmonary  emphysema,  asthma,  and  fibroid 
phthisis,  all  of  which  mean  cardiac  dilatation;  or  due  to  cardiac 
hypertrophy  of  a  high  grade,  fatty  degeneration  of  the  heart  muscle, 
nephritis,  arteriosclerosis,  etc.,  should  not  be  sent  to  a  high  altitude. 
F.  I.  Knight  objects  to  persons  over  fifty  years  of  age.  Tachycardia, 
when  the  pulse  is  much  over  100  per  minute,  and  not  slowing  down 
after  a  long  rest,  is  also  a  strong  contra-indication. 

Amyloid  degeneration  of  visceral  organs,  advanced  laryngeal, 
intestinal,  and  peritoneal  tuberculosis  are  contra-indications.  This 
is  not  because  the  climate  is  harmful,  but  the  hopelessness  of  the 
case  precludes  sending  the  patient  far  away  from  home.  Schroder, 
whose  experience  has  been  very  large,  warns  against  sending  patients 
with  signs  of  commencing  cardiac  weakness  and  with  strongly  accen- 
tuated neuroses  to  an  altitude  of  over  1000  meters  above  sea  level. 


SEA   CLIMATES  501 

In  selecting  patients  for  high  altitude,  we  must  not  put  ver}^  much 
weight  on  the  chmatic  action  on  the  puhnonary  lesion;  it  is  its  influ- 
ence on  the  heart,  bloodvessels,  and  nervous  system  that  is  important. 
If  distinct  disturbances  in  the  structure  or  function  of  these  organs 
are  found,  we  must  warn  the  patient  against  high  climates.  If  there 
are  strong  reasons  for  sending  him  there,  it  must  be  done  slowly — ■ 
sending  him  first  to  a  medium  altitude  and  watching  the  effect,  and 
when  no  harm  is  done  he  may  be  permitted  to  go  higher  and  finally, 
if  he  bears  it  well,  he  maj^  go  up  as  high  as  6000  feet  or  more  above  sea 
level.  It  is  obvious  that  these  experiments  can  only  be  made  with 
economically  independent  patients. 

It  has  been  repeatedly  stated  that  hemoptysis  is  more  likely  to 
occur  in  high  altitudes  than  on  the  plains,  but  this  is  not  substantiated 
by  facts  observed  by  physicians  with  extensive  experience  in  the 
mountains.  All  available  evidence  tends  to  show  that  pulmonary 
hemorrhages  are  no  more  frequent  on  mountains  of  moderate  height 
(2000  to  5000  feet)  than  in  lower  regions.  Some  authors,  like  Turban, 
state  that  it  is  even  less  frequent. 

The  writer  has  sent  many  patients  with  strong  proclivities  to  bleed 
while  in  the  city  to  the  mountains,  and  with  the  improvement  in  the 
general  and  local  conditions,  the  tendencies  to  hemoptysis  also  dis- 
appeared. I  have  often  been  shocked  by  the  advice  given  to  patients 
who  happen  to  get  a  hemorrhage  while  sojourning  in  the  mountains, 
to  leave  at  once,  and  they  are  in  fact  taken,  while  still  bleeding,  on  a  long 
journey.    Moribund  patients  are  thus  brought  to  the  city  occasionally. 

Hemoptysis  may  occur  in  the  mountains  as  well  as  in  lower  regions; 
it  has  not  been  proven  that  it  occurs  more  frequently  in  the  former 
places  than  in  the  latter.  It  seems,  however,  that  the  results  of  a  copi- 
ous hemorrhage  may  be  more  often  serious  in  the  mountains,  espe- 
cially in  patients  with  impaired  circulations,  as  has  been  shown  by  F. 
C.  Smith. ^  His  statistics  show  fifty-six  deaths  from  pulmonary  hem- 
orrhages out  of  a  total  of  524  patients  treated  at  the  U.  S.  Public 
Health  Sanatorium  at  Fort  Stanton,  New  Mexico,  with  an  altitude 
of  6231  feet.  Ten  per  cent,  of  deaths  from  pulmonary  hemorrhages 
are  not  seen  in  other  places. 

Sea  Climates. — Ancient  physicians  recommended  sea  voyages  for 
consumptives.  English  medical  men  of  the  first  half  of  the  nineteenth 
century  considered  long  sea  voyages  indicated  in  many  cases  of  tuber- 
culosis. The  fact  that  they  have  recently  been  abandoned  shows  that 
they  have  not  met  with  success.  But  we  often  meet  with  patients  who 
want  to  take  a  trip  around  the  world  as  soon  as  they  are  told  that 
they  are  tuberculous.  In  other  cases  in  which  it  is  desirable  to  remove 
the  patient  from  his  home  surroundings  the  most  feasible  place  is  at 
the  sea  coast.  In  fact,  there  are  many  cases  in  which,  as  we  have 
just  mentioned,  high  climates  are  contra-indicated,  and  the  patient, 

1  National  Assn.  for  Study  and  Prev.  Tuberc,  1908,  iv,  240. 


502  CLIMATIC   TREATMENT 

anxious  for  some  decided  change,  asks  whether  a  sea  coast  resort  is 
suitable  for  him.  As  was  already  emphasized,  we  must  always  consult 
the  preference  of  the  patient  and  send  him  to  the  place  he  chooses, 
unless  there  are  strong  reasons  against  it. 

It  is  obvious  that  the  air  on  the  high  seas  is  pure  and  free  from 
dust  and  microorganisms;  but  near  the  coast  it  is  greatly  influenced 
by  the  land  climate  as  well  as  by  the  industrial  conditions  in  nearby 
cities.  In  fact  in  some  coast  cities  it  is  overloaded  with  dust  and  soot 
owing  to  factories  in  the  neighborhood. 

But  its  moisture  serves  the  purpose  of  equalizing  the  temperature; 
the  seasonal  differences  are  less  pronounced.  However,  to  this  there 
are  many  exceptions,  and  before  selecting  a  sea  coast  resort,  it  is  best 
to  inquire  carefully  into  the  local  meteorological  conditions. 

According  to  Schroder,^  sea  air  has  a  profound  influence  on  the  heart 
and  bloodvessels.  The  cardiac  activity  is  increased  and  the  pulse 
slowed.  He  explains  it  by  the  action  of  the  strong  air  currents  and 
the  greater  heat  conductivity  of  the  moist  air;  despite  the  decrease 
in  perspiration,  the  skin  is  better  cooled  and  the  bloodvessels  contract. 
Reflexly,  this  causes  a  greater  cardiac  activity  and  the  peripheral 
bloodvessels  dilate,  causing  hyperemia  of  the  skin.  The  result  is 
strong  circulation  of  the  blood  from  the  visceral  organs  to  the  per- 
iphery. The  higher  air-pressure  causes  slower,  but  deeper  respiration, 
favoring  better  metabolism  and  increased  excretion  of  carbon  dioxide. 
The  activity  of  the  skin  and  especially  of  the  mucous  membranes  is 
greatly  augmented. 

Sea  voyages  are  not  to  be  encouraged.  "The  vicissitudes  of  sea 
travel,"  says  Guy  Hinsdale,  "the  narrow  cabins  and  the  difficulty 
of  obtaining  a  suitable  diet,  ev^en  such  common  requisites  as  milk  and 
eggs,  should  be  enough  to  condemn  sea  voyages.  Tuberculous  patients 
ought  not  to  travel  more  than  is  absolutely  necessary.  Imagine  the 
bacteriological  condition  of  a  consumptive's  stateroom,  for  instance, 
at  the  end  of  a  month's  voyage.  What  sea  captain  or  steward  would 
ever  put  such  a  cabin  into  sanitary  condition  for  the  next  passenger?" 
Then  it  must  be  borne  in  mind  that  sea  sickness  is  liable  to  do  much 
liarm.  I  have  seen  many  hopeful  cases  of  tuberculosis  take  a  bad  turn 
after  a  sea  voyage  during  which  they  suffered  from  sea  sickness. 

As  a  therapeutic  measure  sea  voyages  are  therefore  to  be  con- 
demned. But  patients  who  are  known  to  bear  the  travel  well,  and  do 
not  suffer  from  sea  sickness,  may  be  permitted  to  cross  the  ocean  when 
necessary.  They  are,  however,  to  be  warned  against  slow  steamers, 
the  sooner  they  get  across  the  better;  and  they  must  be  told  that  it  is 
best  for  them  to  spend  the  greater  part  of  the  time  on  deck,  and  avoid 
the  close  cabin  and  the  stuffy  smoking-room. 

Empirically,  it  has  been  found  that  incipient  cases  without  pro- 
nounced constitutional  symptoms  often  do  very  well  at  the  sea  coast, 

1  Braucr,  Schrddcr,  and  Blumenfeld's  Handbuch  d.  Tubcrkiilose,  ii,  1914,  335. 


DESERT  CLIMATES  503 

provided  they  observe  the  rules  of  healthful  life.  A  slight  tendency 
to  hemoptysis  is  no  contra-indication,  but  those  who  show  proclivities 
to  copious  hemorrhages,  especially  in  the  advanced  stages,  should 
avoid  the  sea  coast.  Fibroid  phthisis,  as  well  as  cases  of  tuberculosis 
with  extensive  pulmonary  emphysema,  are  better  off  at  the  sea  coast 
than  at  the  mountains  and  I  have  seen  cases  relieved  or  improved, 
though  in  inland  climates  they  had  been  doing  badly.  Similarly 
cases  with  cardiac  and  renal  complications,  which  cannot  be  sent  to 
high  altitudes,  should  be  sent  to  the  sea  coast  when  a  change  is  decided 
upon.  Mild  implication  of  the  larynx  is  no  contra-indication.  The 
cases  of  asthma  and  tuberculosis,  in  which  dilatation  of  the  heart  is 
a  strong  feature  and  which  are  not  relieved,  or  are  harmed  at  a  high 
altitude,  should  be  sent  to  the  seashore  where  they  often  recover  their 
strength  in  a  marvellous  manner.  The  same  is  true  of  senile  consump- 
tives with  rigid  arteries  and  rigid  chests,  in  whom  paroxysmal  attacks  of 
cough  and  expectoration  are  occasionally  very  annoying.  They  are 
often  benefited  by  a  stay  at  the  sea.  Phthisis  with  chronic  bronchitis 
in  which  the  amount  of  expectoration  is  excessive,  is  relieved  at  times 
in  a  sea  climate.  Mild  forms  of  neurosis  and  metabolic  disturbances, 
such  as  gout,  diabetes,  obesity,  etc.,  when  complicated  by  tuberculosis, 
do  well  at  the  seashore. 

Of  course,  far  advanced  cases  with  hectic  or  high  continuous  fever, 
or  with  laryngeal,  intestinal  and  renal  complications,  as  well  as  acute 
progressive  cases,  should  not  be  sent  to  the  sea  coast  but  should  be 
kept  at  home. 

Desert  Climates. — There  yet  remains  to  speak  of  desert  climates 
in  which  many  patients  in  this  country  have  been  cured  by  "  roughing 
it."  These  regions  may  be  of  low  or  medium  altitude.  But  their  most 
important  characteristic  is  the  capriciousness  of  meteorological  con- 
ditions; the  changes  are  quick  and  extreme.  The  air  is  pure — there 
are  usually  not  enough  people  to  contaminate  it — but  it  is  frequently 
filled  with  dust  ar\d  sand,  especially  after  strong  winds  and  storms. 
Of  sunshine  there  is  plenty,  often  to  the  detriment  of  the  patient,  who 
finds  it  hard  to  contrive  a  shelter  against  it. 

Because  of  the  frequent  changes  in  the  weather,  strong,  often  violent 
winds,  these  climates  make  very  great  demands  upon  the  reactive 
powers  of  the  patient,  and  lead  to  excessive  expenditure  of  vital  force. 
They  are  therefore  suited  only  for  those  endowed  with  strong  con- 
stitutions and  who  have  ample  recuperative  powers.  The  very  young 
and  the  very  old  and  those  with  delicate  constitutions,  should  not  be 
sent  to  the  desert.  Moreover,  patients  of  the  class  just  mentioned  as 
proper  cases  for  desert  climate,  are  not  satisfied  with  climate  alone. 
They  demand,  as  a  rule,  also  social  life  and  amusements  to  distract 
them,  and  these  they  cannot  get  in  those  regions. 

It  has  been  found  empirically  that  patients  with  phthisis  compli- 
cated by  bronchitis  and  pulmonary  emphysema,  who  expectorate  exces- 
sively, often  do  well  in  these  regions.     Patients  with  phthisis  compli- 


504  CLIMATIC   TREATMENT 

cated  by  renal  disease  may  also  do  well,  provided  there  is  no  arterio- 
sclerosis. Occasionally,  we  meet  a  patient  in  a  far  advanced  stage  of 
the  disease  who  has  been  "given  up,"  but  he  decided  to  discard  all 
comforts  and  pleasures  of  life  and  leaves  for  some  desert  region,  and 
within  a  couple  of  years  returns  in  excellent  condition.  These  cases 
are  rare,  but  they  do  occur.  Unfortunately,  they  admit  of  no  general- 
ization. 

A  Warning. — Before  leaving  the  subject  of  climatic  treatment  of 
phthisis,  I  want  to  emphasize  the  fact  that  it  is  not  only  good  air,  but 
also  good  residence  and  above  aU  good  food  that  the  patient  must 
have  if  he  is  to  recover.  These  three  in  combination  are  very  difficult 
to  obtain.  William  Garrott  Brown,  an  American  historian,  who  suc- 
cumbed to  phthisis  after  making  a  vain  fight  against  the  disease,  thus 
describes  his  experiences: 

"  It  is  now  seven  years  and  more  since  I  began  my  quest  for  a  place 
and  an  arrangement  to  breathe  freely  and  constantly  the  right  kind  of 
air,  and  eat  in  abundance  the  right  kind  of  food,  yet  I  can  say  with 
perfect  honesty  that  I  have  not  yet  found  anywhere  the  combination 
of  these  two  factors  of  cure  worked  out  satisfactorily  at  moderate 
cost  for  me  and  such  as  I  am."  He  points  out  that  American  cookery 
is  peculiarly  exasperating — "  that  is  to  say,  the  cooking  of  such  Amer- 
icans, doubtless  the  majority,  as  can  be  induced  to  'take  boarders,' 
and  particularly  such  as  can  be  induced  to  take  boarders  who  are 
sick.  Many  of  these  last,  by  the  way,  are  such  as  have  already  failed 
to  minister  acceptably  to  boarders  who  are  well.  There  is,  as  a  rule, 
not  merely  unenlightened  American  cookery,  but  cookery  simulated 
by  no  aspiration  and  but  little  competition;  cookery  seasoned  with  a 
lax  indifference;  cookery  without  any  compelling  need  to  be  better, 
and  with  an  obvious  reason  for  being  as  careless  and  unlaborious  as 
it  can  be  and  continue  to  be  endured.  To  take  'lungers'  at  all,  it 
would  seem,  confers  rather  than  incurs  an  obligation.  For  is  not  that 
surrendering  the  chance  of  any  other  kind  of  gainful  hospitality?" 

These  are  the  reasons  why  many  patients  who  have  done  well  at 
home  take  a  turn  to  the  worse  after  a  sojourn  in  the  country  for  a 
few  months.  Physicians  should  bear  this  food  problem  in  mind  when 
sending  their  patients  to  boarding  houses  in  the  country,  and  when 
the  place  selected  has  an  ideal  climate  but  does  not  have  the  facilities 
for  proper  housing  and  feeding  the  patient,  he  is  safer  at  home  under 
a  carefully  regulated  open-air  treatment,  as  was  already  described. 


CHAPTER  XXXIV. 
INSTITUTIONAL  TREATMENT. 

Sanatoriums. — We  have  shown  that  success  in  the  treatment  of 
tuberculosis  can  only  be  attained  by  gaining  the  confidence  and  the 
cooperation  of  the  patient  and  retaining  them  over  a  long  period  of 
time,  till  the  termination  of  the  case.  The  old  adage  that  rest,  proper 
nourishment  and  fresh  air  are  effective  as  curative  agents,  holds 
good  today.  But  these  can  only  be  of  benefit  when  taken  method- 
ically and  adjusted  to  the  special  requirements  of  each  individual 
case.  The  tuberculous  patient  is  usually  an  individual  who  has  not 
led  an  exemplary  hygienic  life,  as  is  proven  by  the  fact  that  the  error 
of  his  ways  has  been  instrumental  in  reducing  his  natural  and  inherent 
resisting  forces  against  the  ravages  of  the  tubercle  bacilli.  He  must, 
therefore,  be  guided  into  a  healthful  mode  of  life.  He  must  also  be 
cared  for  in  such  a  manner  as  to  preclude  the  dissemination  of  the 
seeds  of  the  disease  among  those  who  come  into  contact  with  him. 

These  are  some  of  the  reasons  why  there  have  recently  been  estab- 
lished institutions  with  a  view  of  solving  the  complex  prophylactic, 
therapeutic  and  social  problems  of  tuberculosis.  In  these  "sanato- 
riums" the  patients  are  under  the  constant  supervision  of  especially 
trained  physicians  who  scientifically  and  methodically  guide  them 
along  climatic,  dietetic  and  specific  lines  of  treatment.  The  rules  of 
rational  life  are  minutely  enforced  and  the  discipline  is  of  a  military 
character  in  practically  all  well-conducted  institutions. 

As  soon  as  a  diagnosis  has  been  made,  the  problem  is  at  once  pre- 
sented whether  the  patient  should  be  sent  to  one  of  these  sanatoriums 
or  may  be  cared  for  at  home  with  an  equal  outlook  for  ultimate 
recovery.  In  deciding  this  question  it  is  necessary  to  take  into 
consideration  many  factors  which  are  but  rarely  thought  of. 

Scope  of  Sanatoriums. — Dettweiler  established  his  first  sanatorium 
in  Germany  in  1859,  at  a  time  when  tuberculosis  was  considered 
incurable  because  of  the  teachings  of  Laennec  and  the  experience  of 
ancient  physicians.  In  this  country  Trudeau  established  the  first 
sanatorium  at  Saranac  Lake  in  1884  and  met  with  considerable  suc- 
cess, discharging  cured  patients,  a  thing  which  was  in  those  days 
considered  impossible.  With  the  evolution  of  our  knowledge  of  the 
etiology,  pathology  and  therapy  of  the  disease,  the  role  of  the  sana- 
torium has  been  greatly  enhanced.  It  was  expected  that  it  would 
prove  of  great  prophylactic  value  by  affording  places  for  the  segrega- 
tion and  isolation  of  the  sick  bacilli  "carriers;"    that  it  would  prove 


506  INSTITUTIONAL   TREATMENT 

of  immense  therapeutic  value  because  it  was  assumed  that  modern 
methods  of  chmatic,  dietetic  and  specific  treatment  can  only  be 
carried  out  under  the  careful  supervision  of  especially  trained  physi- 
cians; that  it  would  prove  of  great  educational  value,  teaching  the 
patients  a  healthful  mode  of  life  which  is  in  itself  an  important  weapon 
in  the  struggle  against  the  disease,  and  which  may  be  followed  by 
them  after  their  discharge  from  the  institutions. 

With  these  aims  in  view,  numerous  institutions  have  been  established 
in  nearly  every  country  of  the  civilized  world  at  an  outlay  of  immense 
sums  of  money  for  buildings,  equipment,  and  maintenance.  In  some 
countries  the  State  or  private  insurance  companies  have  provided  the 
funds  for  the  sanatoriums.  The  fact  that  within  recent  years  the 
mortality  from  tuberculosis  has  decreased  was  striking  proof  of  the 
valuable  results  attained  and  the  sanatoriums  were  given  the  lion's 
share  of  the  credit. 

But  at  present,  after  these  institutions  have  been  in  existence  for 
over  thirty  years,  we  hear  inquiries  from  man}'  competent  sources 
whether  they  have  done  all,  or  the  greater  part  of  what  has  been 
expected  of  them.  Articles  like  that  of  Edward  S.  McSweeny,^ 
Medical  Superintendent  of  the  Sea  View  Hospital  in  New  York,  "Are 
We  Getting  Proper  Value  from  Our  Plant  and  Expenditure  for  the 
Tuberculous?"  are  becoming  more  and  more  frequent  in  our  medical 
journals.  Considering  that  immense  sums  of  money  have  been  invested 
in  these  institutions,  it  is  but  proper  to  inquire  whether  they  have 
brought  returns  along  therapeutic  and  prophylactic  lines  commen- 
surate with  the  investment. 

Limitations  of  the  Usefulness  of  Sanatoriums. — It  seems  that  the 
pessimism  as  to  the  value  of  sanatoriums  displayed  at  present  is 
mainly  due  to  the  fact  that  too  much  was  expected  from  them.  They 
are  no  panaceas  for  phthisis.  Some  enthusiasts  who  have  advocated 
their  erection  and  raised  funds  for  the  purpose  have  in  fact  promised 
too  much  and  when  at  present  these  institutions  do  not  come  up  to  the 
extravagant  expectations  of  some,  they  are  altogether  condemned. 
This  is  as  unjust  as  the  extreme  enthusiasm  of  those  who  claimed 
that  sanatoriums  will  solve  the  tuberculosis  problem.  In  an  official 
report  signed  by  Clifford  AUbutt,  Lauder  Brunton,  Arthur  Latham, 
and  William  Osler,^  on  the  value  of  sanatorium  treatment,  it  is  stated : 
"In  many  cases,  owing  to  the  severity  of  the  disease  present,  it  must 
be  useless;  that  in  a  few  instances  it  is  actually  harmful;  and  that  in 
many  cases  this  method  of  treatment  need  not  be  carried  out  in  an 
institution." 

Before  pointing  out  the  cases  in  which  the  sanatoriums  may  be 
utilized  with  benefit  in  the  treatment  of  phthisis,  we  shall  enumerate 
some  of  the  shortcomings  of  this  method  of  treatment : 

The  number  of  sanatoriums  is  inadequate,  and  we  cannot  expect 

'  Medical  Record,  1915,  Ixxxvii,  94. 
=  Lancet,  1911,  ii,  ISO. 


SANATORIUMS  507 

that  there  will  ever  be  a  sufficient  number  to  provide  for  all  tuber- 
culous patients,  just  as  we  cannot  expect  that  all  suffering  from  active 
disease  can  be  induced  to  enter  and  stay  within  the  institutions  till 
the  termination  of  the  affliction.  In  the  available  institutions  there 
is  hardly  place  for  5  per  cent,  of  the  existing  proper  cases.  To  provide 
accommodations  for  all  suitable  cases  in  the  United  States,  several 
billions  would  have  to  be  invested  in  buildings  and  equipment,  and 
then  at  least  $100,000,000  annually  for  maintenance.  Even  the 
most  enthusiastic  of  those  engaged  in  the  campaign  for  the  control 
of  tuberculosis  are  not  hopeful  of  ever  raising  such  enormous  funds. 

Sanatoriums  are  expensive,  and  it  is  problematical  whether  the 
results  attained  within  them  could  not  be  achieved  in  the  vast  majority 
of  cases  for  a  lesser  expenditure  with  home  treatment.  It  costs  at 
least  $1.50  per  day  to  maintain  a  patient  in  a  sanatorium.  The  experi- 
ment has  never  been  tried  on  a  large  scale  to  spend  that  much  money 
on  a  large  group  of  patients  treated  in  their  homes  consistently  for 
many  months. 

It  appears  that  only  the  very  rich  or  the  very  poor  can  afford  insti- 
tutional treatment  for  months  under  present  conditions.  The  former 
can  pay  any  price,  and  the  latter  are  cared  for  in  enlightened  cities 
by  the  State,  municipal  or  philanthropic  institutions.  But  there  is 
a  large  middle  class  which  will  only  reluctantly  agree  to  be  treated  as 
public  charges,  as  is  the  case  with  clerks,  small  merchants,  profes- 
sional persons,  etc.,  who  have  been  self-supporting  till  stricken  by  the 
disease.  They  cannot  undertake  to  pay  at  least  $20.00  a  week  for 
several  months  and  at  the  same  time  provide  for  those  dependent  on 
them.  Neither  are  they  inclined  to  enter  a  State  or  municipal  sana- 
torium and  associate  with  persons  who  may  be  distasteful  to  them. 
Only  when  the  disease  has  advanced  far,  often  beyond  repair,  and  all 
their  own  and  their  friends'  resources  have  been  exhausted,  do  they 
decide  to  enter  sanatoriums  as  a  last  resort,  and  even  then  they  often 
leave  soon  after  entering  because  the  surroundings  are  distasteful  to 
them.  This  is  the  main  reason  why  so  few  incipient  cases  derived  from 
these  classes  are  entering  sanatoriums. 

It  is  very  difficult  to  induce  patients  in  the  incipient  stage  of  the 
disease  to  enter  sanatoriums  because  they  maintain  that  they  feel  quite 
well  and  resent  the  idea  that  they  must  live  among  ''sick,"  or  among 
"consumptives,"  and  they  often  leave  soon  after  entering  for  these 
reasons.  The  strict  discipline,  especially  the  unavoidable  institutional 
atmosphere,  is  distasteful  to  the  average  human  being  who  will  resist 
all  attempts  to  place  him  in  an  institution  as  long  as  he  can.  The 
policy  of  admitting  only  hopeful  cases  and  discharging  bed-ridden  or 
dying  patients  does  not  meet  with  the  success  worthy  of  the  effort. 

Many  patients  refuse  to  enter  sanatoriums  because  they  do  not 
want  to  have  the  stigma  of  tuberculosis  which,  they  allege,  will  stick 
to  them  throughout  their  life  and  may  interfere  with  getting  employ- 
ment under  present  conditions  of  private  and  municipal  phthisiophobia. 


508  INSTITUTIONAL   TREATMENT 

It  can  be  stated  without  fear  of  meeting  proofs  to  the  contrary 
that,  on  the  whole,  sanatoriums  do  not  show  better  lasting  results  than 
properly  conducted  home  treatment.  In  this  countr}-,  hardly  any 
State  or  municipal  sanatoriums  have  published  satisfactory  reports 
w^ith  comparative  statistics  showing  the  results  attained  as  compared 
with  a  similar  group  of  patients  treated  in  their  homes.  The  most 
competent  compilations  of  statistics  have  been  published  by  Lawrason 
Brown  and  Pope^  about  the  discharged  patients  from  Saranac  Lake, 
and  by  Herbert  Maxon  King-  of  the  Loomis  Sanatorium.  To  be  sure, 
Brown  shows  that  five,  ten,  and  even  eighteen  years  after  discharge 
some  of  the  patients  were  found  alive  and  even  efficient  at  their  occu- 
pations. But  the  average  life  of  the  consumptive  outside  of  the 
institution,  under  any  mode  of  treatment,  has  been  found  to  be  between 
six  or  seven  years.  Stadler^  reports  that  five  years  after  the  onset 
of  the  disease  one-half  of  tuberculous  patients  are  found  who  are 
able  to  work  without  sanatorium  treatment.  There  are  similar 
statistics  available  for  other  countries,  and  I  have  no  doubt  that  in 
the  United  States,  we  would  find  conditions  the  same.  King's  con- 
clusion as  to  the  value  of  sanatorium  treatment  is  that  his  inquiry 
"clearly  demonstrates  the  uncertainty  of  apparent  immediate  results 
of  treatment." 

This  uncertainty  refers  mostly  to  relapses,  wliich  are  to  be  expected 
when  we  consider  the  undulating  coiuse  of  phthisis,  with  its  periods 
of  remissions  and  of  acute  or  subacute  exacerbations.  The  few  investi- 
gations that  have  been  made  of  patients  discharged  from  sanatoriums 
in  New  York  show  distinctly  that  a  very  high  proportion  have  suft'ered 
from  relapses  of  the  disease,  despite  the  fact  that  they  have  been  found 
"apparently  cured,"  or  "improved"  at  the  time  of  their  discharge. 
Many  have  to  be  readmitted  because  of  these  relapses,  and  it  has  been 
said  that  the  cure  is  so  good  and  attractive  that  many  patients  like 
to  take  it  several  times. 

In  estimating  the  problem  whether  sanatoriums  bring  returns  com- 
mensurate with  the  money  invested  in  their  erection  and  maintenance, 
we  must  deduct  those  cases  which  suffer  relapses,  for  obvious  reasons. 
And  when  we  do  this  in  addition  to  combining  with  them  those  who 
have  been  discharged  because  the  sanatorium  was  of  no  benefit  to  them, 
and  also  those  who  died,  we  discover  that  the  cost  per  successful  case 
is  enormous  and  hardly  attractive  to  municipal  and  State  authorities. 

The  educational  value  of  the  sanatoriums  is  beyond  question,  teach- 
ing, as  they  do,  objectively  the  rules  of  healthful  life.  But  the  patients 
of  the  lower  social  strata  who  make  up  the  bulk  of  dependent  con- 
sumptives, cannot,  as  a  rule,  continue  along  the  hygienic  lines  which 
they  have  learned.  Returning  to  the  tenements,  with  rooms  without 
windows  or  baths,  coupled  with  a  low  earning  capacity,  one  can  not 

1  American  Medicine,  1904,  viii,  879;    Ztschr.  f.  Tubcrkulose,  1908,  xii,  206. 

2  National  Assn.  for  Study  and  Prev.  Tuberc,  1912,  viii,  82. 

3  Deut.  Arch.  f.  klin.  Med.,  1902,  Ixxv,  412. 


SANATORIUMS  509 

live  in  the  manner  he  learned  in  an  institution.  Relapses,  which  are 
likely  under  all  circumstances,  are  inevitable  for  these  reasons  alone. 

On  the  other  hand,  the  recent  educational  campaign  carried  on  by 
the  various  antituberculosis  agencies  has  done  all  that  can  be  done 
along  educational  lines.  In  fact,  the  dispensaries  with  their  social 
services,  the  day  and  night  camps,  etc.,  achieve  educational  as  well 
as  therapeutic  results  which  are,  from  a  certain  viewpoint,  superior 
to  and  more  extensive  than  those  of  the  sanatoriums,  and  at  less 
cost. 

Let  us  not  overestimate  the  prophylactic  value  of  the  sanatoriums. 
It  was  hoped  that  by  segregating  consumptives,  sources  of  infec- 
tion would  be  isolated.  But  we  have  already  shown  that  this  was  a 
vain  hope.  Only  "incipient"  cases  are  admitted — as  far  as  they  can 
be  found  and  induced  to  enter  in  time — while  advanced  cases,  which 
are  the  most  dangerous  because  they  expectorate  miriads  of  tubercle 
bacilli,  are  rejected.  The  statement  that  the  institutional  treatment 
is  the  predominant  cause  of  the  dechne  in  the  death  rates  from  phthisis, 
which  has  been  expounded  by  Newsholme^  with  such  vigor,  is  not 
supported  by  facts.  Newsholme's  figures  have  been  demolished  by 
Karl  Pearson,^  one  of  the  most  competent  authorities  to  judge  statis- 
tics. In  Germany — the  home  of  the  sanatorium — this  claim  has  been 
abandoned  during  recent  }'ears.  As  was  pointed  out  by  Cornet  and 
Robert  Koch  at  the  Antituberculosis  Congress  in  London,  there  were 
at  least  226,000  persons  disseminating  tubercle  bacilli  in  Germany, 
and  only  20,000  were  cared  for  in  institutions,  and  of  these  latter  only 
4000  expectorated  bacilli.  This  number  could  not  have  had  any  per- 
ceptible influence  on  the  morbidity  and  mortality  from  tuberculosis. 
In  the  United  States  conditions  are  the  same. 

From  the  clinical  standpoint,  we  are  not  in  possession  of  reliable 
statistics  showing  that  the  mortality  of  patients  who  have  been 
treated  in  sanatoriums  is  lower  than  that  of  those  who  have  been 
cared  for  in  their  homes.  We  have  already  mentioned  that  the  insti- 
tutions in  the  United  States  have  not  published  comprehensive  data 
along  these  lines,  excepting  those  by  Lawrason  Brown  and  King. 
In  Germany,  although  long  and  apparently  learned  books  and  articles 
have  been  produced,  they  are  just  as  much  in  the  dark  about  this 
problem  as  we  are  in  this  country.  The  reasons  are  that  the  material  is 
not  comparable.  A  drastic  illustration  may  be  cited.  In  the  selection 
of  cases  it  is  aimed  at  admitting  only  those  in  the  incipient  stage.  The 
result  is  that  at  Grabowsee  45.2  per  cent.,  and  at  Melsungen  97 
per  cent,  of  the  patients  have  not  shown  any  tubercle  bacilli  in  the 
sputum.  Ulrici  reports  that  in  40  per  cent,  of  the  patients  at  INIulrose 
he  could  not  make  a  positive  diagnosis  of  tuberculosis,  and  Leube 
says  that  many  patients  who  are  admitted  to  sanatoriums  in  Germany 

1  The  Prevention  of  TuVjerculosis,  London,  1908. 

2  The  Fight  against  Tuberculosis  and  the  Death  Rate  from  Phthisis,  London,  1911; 
Tuberculosis,  Heredity  and  Environment,  London,  1912. 


510  INSTITUTIONAL   TREATMENT 

are,  when  examined  by  military  surgeons,  found  fit  for  the  army,  and 
accepted. 

It  is  obvious  that  statistics  of  such  "consumptives"  will  show  good 
and  lasting  results  of  treatment.  In  their  book  on  the  prognosis  of 
tuberculosis  Kuthy  and  Wolff -Eisner,  reviewing  the  subject,  say  that 
exact  and  scientific  data  are  not  available  to  prove  the  value  of  sana- 
torium treatment;  and  Newsholme,  who  is  a  great  believer  in  the 
benefits  of  institutional  treatment,  also  says  that  there  are  no  exact 
and  comparable  data  available  to  prove  it. 

Causes  of  Failure  of  Institutional  Treatment  from  the  Therapeutic 
Viewpoint. — While  institutional  treatment  undoubtedly  has  its  advan- 
tages, which  will  be  shown  later  on,  it  is  by  no  means  the  best  and 
clinicians  cannot  approve  of  all  the  methods  pursued  in  sanato- 
riums.  The  fact  is,  wholesale  treatment  of  such  a  complex  disease  as 
phthisis  is  not  ideal.  Individualization  is  here  of  greater  importance 
than  in  most  other  diseases.  Says  Albert  Robin :^  "One  of  the  dis- 
advantages of  the  sanatorium  is  that  it  applies  too  often  arbitrary 
principles  to  patients  whose  disease  can  only  be  relieved  by  individual- 
ized methods.  It  is  for  this  reason  that  the  practitioner  who  knows  how 
to  adapt  the  treatment  to  each  of  the  small  number  of  patients  under 
his  care,  and  to  take  cognizance  of  the  temperamental  indications,  is 
qualified  to  manage  a  case  of  tuberculosis  as  well  as,  if  not  better  than, 
the  sanatorium  doctor  who  has  under  his  care  a  large  number  of 
patients  of  whose  individual  idiosyncracies  he  is  ignorant,  at  least 
for  a  time,  and  must  therefore  have  a  strong  tendency  to  subject  them 
all  to  the  same  method  of  treatment."  Charles  L.  Minor  says:  "By 
seeing  our  patients  too  frequently — as  we  do  if  we  live  in  the  same  house 
with  them — we  are  apt  to  lose  that  objectivity  in  our  attitude  toward 
them  which  is  so  important;  and  to  lessen  rather  than  increase  our 
control."  This  refers  to  private  sanatoriums,  in  which  the  patients 
must  be  catered  to,  if  they  are  to  be  retained  for  months.  In  state 
and  municipal  sanatoriums,  where  the  poor  and  dependent  patient 
faces  starvation  if  he  leaves  the  institution,  the  trouble  is  of  a  diametric- 
ally opposite  character.  The  fact  that  a  large  proportion  of  patients 
leave  before  the  physicians  discharge  them  shows  that  they  cannot 
be  satisfied. 

This  lack  of  individualization  in  treatment  is  seen  in  many  ways  in 
the  sanatoriums  which  are  hotbeds  of  therapeutic  hobbies.  But  this 
is  usually  not  as  harmful  as  the  uniformity  of  the  diet  in  institutions. 
Mass  feeding  is  difficult  at  best  and  can  only  be  carried  out  in  jails, 
where  the  inmates  have  no  choice,  or  in  armies  during  war.  To  sub- 
ject to  the  same  dietary  tuberculous  patients  in  different  stages  of  the 
disease  with  different  individual  capacities  for  digestion  and  assimi- 
lation, who  have  been  brought  up  on  and  adapted  to  difi'erent  kinds 
and  preparations  of  foods,  is  bound  to  meet  with  failure.     For  this 

'  Traitenieut  de  la  tubeiculose,  Paris,  1912,  p  .67. 


INDICATIONS  FOR  INSTITUTIONAL   TREATMENT         511 

reason  we  find  that  complaints  about  the  quantity  and  quality  of  the 
food  are  universal  in  public  sanatoriums,  and  to  some  extent  in  private 
institutions  where  food  is  served  a  la  carte. 

.  It  can  hardly  be  expected  that  municipal,  State,  and  philanthropic 
sanatoriums  should  supply  food  a  la  carte;  it  will  always  be  table 
d'hote.  And  for  this  reason  resentment  on  the  part  of  the  patients 
is  to  be  expected.  To  be  sure,  these  institutions  are  always  filled  and 
there  is  a  long  waiting  list.  But  when  patients  leave  before  they  are 
discharged,  we  may  safely  assume  that  the  cost  incurred  during  sev- 
eral weeks  or  months  for  their  maintainence  was  to  a  large  extent 
wasted. 

In  American  municipal  sanatoriums  of  the  large  industrial  cities 
the  failure  in  this  regard  is  even  greater  than  in  other  countries, 
because  we  must  care  for  tuberculous  immigrants  of  various  nation- 
alities whose  tastes  differ  extremely  as  regards  food  and  its  preparation, 
as  is  shown  elsewhere  in  this  book. 

These  are  some  of  the  drawbacks  of  sanatorium  treatment.  It  is  for 
these  reasons  that  the  municipal  and  State  sanatoriums  in  many  cities 
of  the  United  States  are  not  filled  with  a  desirable  element,  but  con- 
tain a  large  proportion  of  underserving  individuals.  "My  efforts 
are  not  going  to  be  devoted  to  coddling  tramps  and  other  parasites," 
exclaims  in  despair  Dr.  Edward  S.  McSweeny,  the  Medical  Superin- 
tendent of  the  Sea  View  Hospital  in  New  York.  These  are  also  the 
reasons  why  the  best  elements  of  the  tuberculous  population  in  this 
country  will  always  have  to  be  cared  for  in  their  homes,  as  is  the  case 
at  present. 

Indications  for  Institutional  Treatment. — But  there  are  many  cases 
of  tuberculosis  which  cannot  be  treated  in  any  other  place  but  in  insti- 
tutions. In  fact  any  one  with  experience  in  a  large  city  is  convinced 
that  tuberculosis  cannot  be  managed  without  the  aid  of  institutional 
treatment.  Of  the  cases  which  are  suitable  for  sanatorium  treatment 
and  would  be  lost  without  it,  we  may  mention  the  following: 

Among  well-to-do  patients  we  meet  with  many  who,  for  various 
reasons,  cannot  be  cared  for  in  their  homes.  To  send  them  to  the 
country  without  control  may  prove  disastrous,  because  the  foolish 
and  reckless  rich  show  at  times  greater  lack  of  self-restraint  than  the 
stupid  poor.  They  are  best  cared  for  in  private  sanatoriums  in  which 
most  of  the  drawbacks  of  the  public  institutions  are  eliminated.  They 
may  be  sent  to  sanatoriums  for  a  short  stay,  over  the  hot  summer 
months,  or  for  outdoor  treatment  for  the  relief  of  an  acute  exacerba- 
tion, etc.;  or  for  a  long  period  till  the  disease  is  arrested.  Great  care 
should  be  taken  that  they  do  not  become  egocentric,  excessively 
introspective,  or  hypochrondriacs,  which  is  not  unusual. 

Among  the  poor  and  those  who  have  become  dependent  because  of 
the  disease,  we  meet  with  a  large  number  of  patients  who  have  no 
family  to  care  for  them  during  their  illness  and,  with  or  without  funds, 
they  are  unable  to  find  lodgings  under  present  conditions  of  rampant 


512  INSTITUTIONAL   TREATMENT 

phthisiophobia.  Many  boarding  houses  bar  persons  who  cough ;  and 
at  times  even  near  relatives  are  overtaken  with  a  sense  of  stupid  fear 
of  infection  and  want  to  get  rid  of  the  unfortunate  patient.  For  these 
there  is  left  nothing  but  to  go  to  a  well-regulated  sanatorium. 

There  is  a  large  number  of  phthisical  patients  who  notoriously  lack 
will  power  to  carry  out  the  most  important  of  the  measures  pre- 
scribed for  them  and,  remaining  in  the  city,  they  are  apt  to  be  tempted 
by  the  opportunities  for  gay  life  or  even  excesses.  They  are  better 
off  in  sanatoriums. 

On  the  other  hand,  there  are  many  who  show  all  willingness  to  do 
everything  that  is  conductive  to  the  cure  of  the  disease,  but  they 
have  not  the  funds  to  pay  for  capacious  rooms  in  a  desirable  part  of 
the  city,  for  good  nourishment  and  medical  attendance.  Tuberculosis 
is  after  all  the  most  expensive  of  diseases,  not  only  for  the  special 
and  costly  nourishment  and  residence  which  are  required,  but  mainly 
for  the  long  time  the  patient  must  remain  idle  and  the  savings  of  years 
may  be  exhausted  before  he  can  resume  work.  While  most  of  these 
can  be  and  are  well  cared  for  in  the  clinics,  the  day  and  night  camps 
found  in  every  large  city  at  present,  we  meet  with  many  who,  for 
obvious  reasons,  are  better  off  in  sanatoriums,  at  least  for  short  stays. 

Most  phthisical  patients  should  leave  the  city  during  the  hot  summer 
months,  and  those  who  cannot  raise  the  funds  for  the  purpose  are 
proper  charges  of  the  sanatoriums.  Indeed,  if  the  sanatoriums  were 
not  filled  with  lazy,  undeserving  tramps  and  vagrants  who  remain  for 
years  in  the  institutions,  and  when  discharged  from  one,  soon  gain 
admission  to  another,  they  could  well  care  for  the  just  mentioned  class 
of  patients.  It  seems  to  me  that  the  German  system  of  admitting 
tuberculous  patients  for  three  or  four  months  is  much  superior  to  ours, 
where  they  are  often  kept  indefinitely.  The  result  is  that  the  patients 
must  wait  for  months  before  beds  are  vacant  for  them  and  truly 
incipient  cases,  left  without  proper  care  while  waiting  for  admission, 
become  advanced. 

The  longer  we  are  up  against  the  problems  presented  by  tuberculosis 
in  the  city,  the  more  we  are  convinced  that  the  public  sanatoriums 
ought  to  be  converted  into  hospitals  which  admit  patients  on  short 
notice,  keep  them  for  a  few  weeks,  a  month  or  two,  until  they  regain 
their  strength  and  are  fit  for  treatment  in  the  clinics.  Patients  who 
suffer  from  acute  exacerbations  during  the  long,  chronic  course  of 
phthisis  could  then  be  cared  for.  Inasmuch  as  municipal  institutions 
are  now  in  abundance  near  cities,  this  could  easily  be  accomplished. 

But  sanatoriums  still  work  on  the  theory  that  they  are  to  cure 
their  patients,  which  they  cannot  do  in  more  than  5  or  10  per  cent, 
of  cases,  which  is,  in  fact,  not  more  than  home  treatment  accomplishes. 


CHAPTER  XXXV. 
DIETETIC  TREATMENT. 

Economic  Aspects  of  Dietetics  for  Consumptives. — Because  phthisis 
is  accompanied  by  wasting  of  the  body  it  requires  careful,  generous, 
and  at  times  excessive  nourishment  with  a  view  to  covering  the  deficit 
created  by  the  extravagant  drain  resulting  from  the  toxemia,  fever, 
loss  of  appetite,  disturbed  digestion,  faulty  metabolism  and  con- 
comitant emaciation.  Cornet  suggests  that  the  rapid  waste  of  the 
tissues  tends  to  hasten  absorption  of  the  proteins  surrounding  the 
tuberculous  foci  and  thus  at  the  same  time  inhibits  the  natural  pro- 
cess of  healing  by  means  of  induration  and  also  furthers  the  per- 
ipheral dissemination  of  the  bacilli.  Inasmuch  as  the  disease  finds 
most  of  its  victims  among  the  poor  and  destitute,  or  causes  destitu- 
tion and  despondency  in  those  who  have  been  self-supporting  before 
its  onset,  the  dietetic  problems  are  not  only  of  a  physiological  nature 
but  also  have  important  economic  bearings.  It  is  self-evident  that  a 
dependent  consumptive  must  not  be  prescribed  food  which  is  beyond 
his  reach  financially. 

In  my  experience  the  dietetics  of  phthisis  are,  in  fact,  more  depen- 
dent on  the  financial  resources  of  the  patient  than  on  the  careful  calcu- 
lation of  the  number  of  calories  contained  in  the  various  foodstuffs. 
Considering  the  variety  of  dietaries  which  have  been  urged  by  various 
authors  in  this  disease,  and  that  each  author  claims  good  results  with 
his  method,  it  is  obvious  that  no  specific  diet  has  been  devised  which  will 
suit  every  case.  In  fact,  all  that  can  be  stated  is  that  tuberculous 
patients  need  food,  just  like  other  persons  who  are  underfed,  but  they 
usually  need  more  of  it. 

Need  for  Individualization  of  Diet. — Most  of  the  studies  in  the 
dietetics  of  phthisis  have  been  carried  out  in  sanatoriums,  some  of 
which  have  had  sufficient  funds  for  an  extravagant  diet,  while  others 
with  meager  finances  have  shown  similar  results.  But  the  lessons 
from  institutional  experience  are  not  applicable  in  their  entirety  to 
patients  treated  in  their  homes.  On  the  other  hand,  the  time-honored 
advice  given  to  tuberculous  patients:  "Eat  plenty  of  milk,  eggs,  and 
meat,"  is  often  decidedly  harmful  to  those  who  follow  it  implicitly. 

There  is  great  urgency  for  individualization  of  the  diet  in  phthisis; 
it  is  important  that  the  diet  should  be  adapted  to  the  needs  of  the 
patient  and  not  to  the  disease.  The  "personal  equation"  counts  for 
more  than  the  disease. 

There  is  no  doubt  that  the  failure  of  institutional  treatment  of 
33 


514  DIETETIC   TREATMENT 

phthisis  is,  in  a  large  measure,  due  to  negHgence  in  this  regard.  Whole- 
sale feeding  is  usually  disastrous  for  human  beings.  The  food  in 
first  class  table  d'hote  restaurants  is  usually  unbearable  to  the  average 
person  when  relied  on  continually  for  a  considerable  time.  It  is  im- 
possible to  make  up  a  menu  which  will  suit  the  palate,  digestive 
capacities,  and  functions  of  one  hundred  patients  in  an  institution 
where  they  must  remain  for  months.  The  difficulties  are  greater 
with  tuberculous  patients  whose  gastric  functions  are  very  often 
deranged.  Tuberculou'S  patients  cannot  be  treated  like  soldiers  in 
the  army  or  prisoners,  if  we  are  to  succeed  in  our  aims. 

It  is  not  true  that  two  kinds  of  food  of  different  composition,  but 
theoretically  of  the  same  nutritive  value,  will  invariably  be  of  the 
same  digestibility  or  produce  the  same  effects.  It  may  be  calculated 
in  the  laboratory  that  a  portion  of  beef  steak,  roast  beef,  poultry,  sau- 
sages, stew,  cheese,  potatoes,  cereals,  bread,  milk,  eggs,  etc.,  contains  a 
certain  proportion  of  proteins,  fat,  and  carbohydrates  and  will  liberate 
a  certain  number  of  calories  when  burned  in  the  body.  In  fact,  we 
know  that  the  intrinsic  value  of  three  eggs  is  equivalent  to  about 
100  grams  of  red  meat,  while  100  grams  of  bread  is  approximately 
equal  to  one  egg,  or  30  grams  of  beef,  or  200  grams  of  potatoes  or 
280  grams  of  milk.  But  very  often  a  consumptive  assimilates  tliree 
eggs  more  easily  than  100  grams  of  beef,  or  300  grams  of  bread.  At 
times  the  patient  assimilates  250  grams  of  milk  better  than  200  grams 
of  potatoes.  Because  of  the  personal  equation  many  patients  refuse 
to  thrive  on  scientifically  prepared  dietaries.  An  Irishman  resents 
spaghetti,  an  Italian  refuses  Irish  stew,  a  German  prefers  sausages  to 
the  English  roast  beef,  etc. 

For  these  reasons,  in  prescribing  a  diet  for  a  patient  we  must  always 
take  into  careful  consideration  his  habits  of  life,  the  foods  upon  which 
he  has  been  raised  and  his  personal  likes  and  dislikes.  Even  when  a 
change  is  imperative,  it  is  dangerous  to  institute  it  suddenly,  and 
we  must  make  a  strong  effort  to  fit  the  diet  to  the  one  the  patient 
has  been  used  to.  The  factors  which  should  guide  us  are  the  presence 
or  absence  of  anorexia,  fever,  constipation,  diarrhea,  etc. 

Superalimentation  and  Forced  Feeding. — With  a  view  of  replenish- 
ing the  wasted  tissues,  especially  in  those  who  are  by  nature  bad  eaters, 
it  has  been  suggested  that  superalimentation  or  even  forced  feeding 
is  indicated  in  most  cases  of  phthisis.  It  has  been  observed  that 
occasionally  an  emaciated  patient  gains  in  weight  under  such  a  regime, 
and  some  authors  have  advised  that  all  sufferers  from  phthisis  should 
be  "stuft'ed."  Even  Debove's  method  of  introducing  food  through 
the  stomach  tube  into  those  who  would  otherwise  not  consiune  large 
quantities  of  noiu'ishment,  was  in  \'ogue  for  some  time  till  it  was  found 
that  the  gain  in  weight  which  forced  feeding  produced  in  some  cases  was 
not  necessarily  an  indication  that  the  lesion  in  the  lung  had  improved. 
It  was  also  found  that  many  patients  imder  forced  feeding,  with  or 
without  the  stomach  tube,  may  gain  in  weight  and  impro\'e  otherwise 


DO  ALL   TUBERCULOUS  PATIENTS  NEED  SPECIAL   DIETS     515 

for  some  time  when  suddenly  the  gastro-intestinal  tract  rebels,  and 
within  a  few  days  they  lose  more  than  they  gained  in  several  months. 

Estimation  of  the  Nutrition  of  the  Patient. — In  our  attempts  at  esti- 
mating the  results  of  certain  dietetic  methods  in  tuberculosis  we  can- 
not always  be  guided  by  the  scientific  determination  of  the  number 
of  calories  ingested  by  the  patient  every  day;  nor  even  by  the  quan- 
tity of  proteins,  fat,  and  carbohydrates  which  the  patient  has  con- 
sumed. Attempts  along  these  lines  have  proved  futile  in  practice; 
they  have  not  given  us  a  diet  which  will  suit  all,  or  the  vast  majority 
of  cases.  It  seems  that  only  chnical  observation  of  the  individual 
patient,  his  state  of  nutrition,  his  digestive  capacity  and  the  assimi- 
labihty  of  the  ingested  food  are  of  value  in  this  regard. 

We  aim  at  increasing  the  amount  of  nourishment  so  that  the  patient 
shall  gain  in  weight,  and  remain  stationary  at  somewhat  above  his 
usual,  or  normal  weight  before  the  onset  of  the  disease.  While  in 
the  vast  majority  of  cases  a  gain  in  weight  is  a  good  index  of  the 
value  of  the  diet,  it  b,  however,  often  liable  to  mislead.  We  very  often 
see  patients  who  prove  that  fattening  by  no  means  goes  hand  in  hand 
with  enhancing  the  resistance  against  the  tuberculous  toxemia.  We 
also  meet  with  cases  with  hardly  any  gain  in  weight,  in  fact  remaining 
under  the  standard  weight,  yet  the  lesion  in  the  lung  heals  and  recovery 
is  good. 

"The  main  object  of  dietetic  treatment,"  says  Brown,^  "is  to  enable 
the  patient  to  regain  his  lost  weight,  but  not  to  make  him  a  flabby, 
breathless  mass  of  inert  fat."  Excessive  nourishment,  which  increases 
the  weight  of  a  patient  more  than  two  or  three  pounds  per  month 
on  the  average,  is  apt  to  result  in  an  overload  of  fat  and  water  without 
any  utility.  We  should  strengthen  but  not  fatten  the  patient.  "  When 
a  workman  has  to  perform  hard  work  he  eats  meat,"  says  Daremberg,^ 
"The  consumptive  has  to  perform  a  very  hard  task,  the  task  of  re- 
pairing his  wasted  body."  In  fibroid  phthisis  obesity  is  not  rare — 
"obesite  toxique"  of  the  French — and  is  often  more  annoying  to  the 
patient  than  the  symptoms  in  the  respiratory  organs. 

In  the  average  case  we  may  judge  the  progress  of  the  disease  by 
following  the  weight  of  the  patient,  provided  we  also  take  other  factors 
into  consideration.  With  the  increase  in  weight  there  should  also  be 
an  increase  in  strength;  physical  examination  should  also  show 
regression  of  the  signs  in  the  lungs,  the  cough  should  be  ameliorated, 
and  the  quantity  of  sputum  decreased.  With  such  signs,  a  slow  and 
persistent  gain,  finally  reaching  ten  to  fifteen  pounds  higher  than 
the  patient's  normal  weight  before  he  was  attacked  by  phthisis,  indi- 
cates that  we  may  be  satisfied  that  the  diet  is  good. 

Do  All  Tuberculous  Patients  Need  Special  Diets? — A  large  propor- 
tion of  phthisical  patients,  probably  one-third  of  all,  have  good  appe- 
tites and  digestion.   In  fact,  even  febrile  consumptives  are  seen  without 

1  Osier's  Modern  Medicine,  i,  482. 

2  Les  differentes  formes  cliniques  de  la  tuberculosa  pulmonaire,  Paris,  1905,  p.  149. 


516  DIETETIC   TREATMENT 

anorexia  which  accompanies  nearly  all  other  fevers.  The  prognosis 
is  good  as  long  as  they  retain  their  gastro-intestinal  functions.  They 
may  be  told  that  a  moderate  increase  in  the  quantity  of  food  they  have 
been  accustomed  to  eat  is  sufficient  and,  when  possible,  they  should 
increase  somewhat  the  quantity  of  proteins  and  fats,  •  provided  the 
stomach  does  not  rebel. 

If  the  constitutional  symptoms  are  in  abeyance  or  disappearing 
and  the  signs  in  the  lung  show  that  the  lesion  is  cicatrizing,  we  should 
not  worry  about  a  lack  of  gain  in  weight,  or  even  when  they  show 
a  few  pounds  less  than  their  normal  weight.  A  patient  with  a  good 
appetite  and  digestion  needs  no  special  diet;  he  should  eat  just  like 
any  other  person,  or  a  little  more,  if  he  can  without  inconvenience. 
On  this  point  all  authorities  agree  today.  Thus,  King^  says:  "In  the 
absence  of  certain  complications,  a  diet  which  would  suffice  for  the 
same  individual  under  normal  conditions  of  life  will  doubtless,  with 
very  slight  modifications,  meet  the  requirements  in  the  presence  of 
tuberculosis,  the  more  especially  during  that  period  of  the  disease 
when  constitutional  symptoms  are  either  absent  or  but  slightly  mani- 
fest." Paterson,^  whose  patients  work  at  graduated  labor,  gives 
them  "a  liberal  diet  which  consists  of  the  ordinary  food  which  the 
working  classes  provide  for  themselves  when  they  are  in  a  position  to 
afford  it."  In  fact,  patients  who  tend  to  become  excessively  fat  have 
their  diet  reduced  in  quantity. 

On  the  other  hand,  patients  who  lose  progressively  in  weight  and 
strength,  are  anemic  and  debilitated  despite  the  rest  which  is  rigidly 
enforced,  need  more  and  better  food  if  they  are  to  recover  or  hold  their 
own  in  the  struggle  with  the  disease.  But  even  here  superalimentation 
must  be  carefully  adapted  to  the  digestive  capacity  of  the  patient. 

It  may  be  stated  as  a  general  rule  that  the  suggestion  of  some 
authors  that  in  such  cases  the  patients  must  consume  between  4500 
and  6000  calories  daily  is  a  dangerous  one.  Experience  has  taught 
that  one  who  will  not  recover  or  hold  his  own  on  a  diet  of  3500  calories, 
will  not  recover  at  all.  Professor  Fisher^  says:  "We  may  feel  satisfied 
that  given  proper  food  elements,  the  average  tuberculous  patient  can 
be  successfully  nourished  on  3000  calories  per  day.  In  other  words 
on  no  more  than  is  usually  consumed  by  the  sedentary  man."  N. 
D.  Bardswell  and  John  E.  Chapman^  have  arrived  at  the  same  con- 
clusion after  a  thorough  experimental  study  of  the  subject. 

Variety. — The  first  principle  to  be  observed  in  the  diet  of  the  tuber- 
culous patient  who  is  losing  weight  is  variety,  both  as  regards  nutritive 
principles  as  well  as  appetizing  qualities.  There  is  nothing  more 
abhorent  to  a  tuberculous  patient,  and  to  a  large  extent  to  all  sufterers 
from  chronic  diseases,  than  homo^geneity  of  diet.  No  limited  and 
exclusive  diet  can  keep  a  patient  well  for  any  length  of  time  because 

1  Sixth  Intern.  Congr.  Tuberc,  19(),S,  i,  719. 

2  Ibid,  p.  893.  •■'  Ibi.l,  p.  ()94. 
^  Diets  in  Tuberculosis,  London,  1908. 


PRECAUTIONS   TAKEN  WHEN  OVERFEEDING  PATIENTS   517 

it  does  not  respond  to  the  urgent  demands  of  the  different  organs  and 
tissues  of  the  body.  It  does  not  stimulate  the  secretions  of  all  the 
digestive  glands.  If  an  exclusively  animal  diet  is  taken,  only  the  gas- 
tric juice  is  stimulated,  while  the  saliva,  pancreatic  juice,  bile,  and 
intestinal  juices  are  not  utilized  and,  remaining  free  in  the  gastro- 
intestinal tract,  are  apt  to  act  as  irritants  and  produce  diarrhea  which 
is  exhausting,  or  constipation  which  is  harmful  in  other  ways. 

We  often  meet  with  patients  who  have  been  given  diet  lists  in 
which  four  or  five  meals  are  listed  for  the  day.  But  any  appetite 
they  may  have  had  before  the  list  was  consulted  promptly  disappears, 
because  it  shows  the  foods  which  have  been  given  them  for  months 
without  any  appreciable  variation.  Many  patients  who  have  followed 
the  injunction  "plenty  of  milk  and  eggs"  have  engendered  such  an 
aversion  to  these  articles  that  the  mere  mention  of  an  egg  is  sufficient 
to  disturb  the  slight  appetite  for  other  foods  which  was  called  forth 
by  hunger.  It  is  always  advisable  to  consult  the  patient  as  to  the  kind 
of  food  he  prefers  or  longs  for  and,  if  there  are  no  contra-indications, 
to  give  it  to  him. 

Precautions  to  be  Taken  when  Overfeeding  Patients. — Before  a 
patient  is  urged  on  to  a  course  of  superalimentation  certain  precau- 
tions are  to  be  taken:  He  must  be  carefully  examined  with  a  view  of 
ascertaining  whether  or  not  he  can  stand  additional  feeding.  Those 
showing  signs  of  arteriosclerosis,  nephritis,  gall-stones,  nephrolithiasis, 
or  gout  should  not  be  allowed  superfeeding,  especially  with  animal 
proteins.  It  is  likely  to  throw  a  considerable  strain  on  the  kidneys 
or  even  produce  albuminuria.  The  condition  of  the  stomach  is  to  be 
ascertained,  and  those  having  dilated  organs,  or  disturbances  in  the 
tonicity  and  motility  of  the  viscus  are  to  be  treated  for  these  troubles 
when  practicable.  The  appetite  is  of  great  importance.  Although 
we  may  succeed  with  some  patients  in  urging  them  to  eat  irrespective 
of  the  appetite,  we  will  fail  with  many. 

Proper  preparation  of  food  goes  a  long  way  in  counteracting  anorexia ; 
Dettweiler  said  that  the  kitchen  was  his  pharmacy.  It  is  better  tO' 
give  the  patient  small  quantities  of  each  of  several  dishes,  well  and 
appetizingly  prepared,  than  large  quantities  of  one  or  two  dishes. 
The  fact  that  the  food  value  is  theoretically  sufficient  in  the  latter 
case  does  not  alter  matters.  With  some  patients  animal  food  should 
predominate,  with  others  eggs  and  with  still  others,  milk.  The  diet 
must  be  frequently  changed,  especially  when  the  digestive  tract 
shows  signs  of  rebellion. 

With  well-to-do  patients  these  are  simple  matters,  but  with  the  poor 
the  problem  is  often  hard  to  solve.  The  writer  usually  sends  for  the 
mother,  wife,  or  sister  of  the  patient  and  gives  her  directions  along 
these  lines. 

Bearing  in  mind  that  the  disease  is  likely  to  last  for  months,  if  not 
for  years,  we  must  spare  the  digestive  organs,  the  cornerstone  of 
phthisiotherapy,  as  they  have  been  called,  and  not  overburden  them 


518  DIETETIC   TREATMENT 

with  work.  The  first  imperative  principle  is  proper  mastication. 
But  regularity  in  meals  is  of  the  same  importance.  The  menus 
of  some  authors  mention  six  and  more  meals  a  day,  which 
are  excessive  in  my  experience.  Three,  at  most  four  meals  a  day  are 
sufficient  for  most  patients,  and  afford  some  rest  to  the  stomach 
between  the  meals.  At  all  events,  the  stomach  must  be  given  a 
complete  rest  during  the  night,  which  can  be  done  by  avoiding  all  food 
between  9  p.m.  and  7  a.m. 

ProtGid  Foods. — Experimental  researches  of  Richet  and  Heri- 
court  and  others  have  proven  conclusively  that  when  ingested  raw, 
animal  foods  have  an  especially  beneficial  effect  in  tuberculosis.  The 
specific  effect  seems  to  reside  more  in  the  juices  of  the  meats  than  in 
the  fiber.  Herbivorous  animals,  like  the  cow,  are  more  prone  to 
tuberculosis  than  carnivorous  animals,  as  the  dog. 

The  best  source  of  proteins  for  a  tuberculous  patient  is  animal 
food,  the  proteins  of  vegetable  origin  are  not  as  easily  assimilated. 
Meats  possess  all  the  qualities  which  are  necessary  for  the  nutrition 
of  the  consumptive.  To  be  sure  there  are  some  who  maintain  with 
Kellogg^  that  a  low  protein  diet  is  productive  of  better  results,  and  urge 
vegetable  proteins  in  the  dietetic  management  of  the  malady.  It  is, 
however,  an  every  day  observation  that  the  animal  proteins  do  not 
tax  the  digestive  organs  to  excess  and,  excepting  in  those  who  suffer 
from  some  form  of  dyspepsia,  they  can  be  taken  by  most  consumptives 
without  difficulty  in  comparatively  large  quantities.  Beef,  mutton, 
lamb,  poultry,  game,  fish,  oysters,  eggs,  milk,  cheese,  etc.,  offer  a  wide 
range  of  choice  for  variety. 

Those  who  have  no  natural  abhorence  for  raw  meat  may  have  it 
with  great  benefit — zomotherapy  was  at  one  time  very  popular,  and 
should  be  utilized,  when  tolerated.  Some  patients  are  not  averse  to 
taking  small  pieces  of  raw  beef,  dipping  it  in  tomato  sauce  and  eating 
it.  It  is,  however,  better  to  mince  or  chop  it,  and  eat  it  between  two 
slices  of  bread  as  a  sandwich,  but  it  should  be  seasoned  to  taste. 
The  vast  majority  of  patients,  however,  prefer  roasted  or  boiled  beef, 
mutton,  poultry,  etc.  It  must  be  mentioned  that  when  roasted  or 
broiled,  meats  should  be  rather  underdone  and,  on  the  whole,  they 
should  be  changed  often. 

But  it  should  never  be  excessive;  we  cannot  rely  on  animal  foods 
exclusively  in  nourishing  a  tuberculous  patient.  To  supply  a  patient 
with  5000  calories  per  day,  it  would  be  necessary  to  gorge  him  with 
six  and  a  half  pounds  of  meat,  or  thirty-six  eggs,  or  five  quarts  of 
milk,  or  two  pounds  of  cheese.  This  would  be  too  much — no  human 
being  could  take  it  with  impunity  for  any  length  of  time.  For  this 
reason  other  foodstuffs  are  necessary  in  addition  to  the  animal  food. 
The  most  the  average  consumptive  should  have  is  about  three-fourths 
to  one  pound  of  meat,  and  when  taken  raw,  it  should  not  exceed  one- 

»  Sixth  Intern.  Congr.  Tuberc,  1908,  iii,  740. 


MILK  519 

half-pound  per  day.  When  this  is  taken  with  one  pound  of  bread, 
three  eggs,  one  quart  of  milk,  eight  ounces  of  potatoes,  and  four 
ounces  of  fresh  vegetables,  the  diet  is  complete. 

A  consumptive  needs  more  protein  foods  than  a  healthy  person 
because  the  disease  destroys  the  tissues,  especially  the  muscles,  and 
there  are  no  better  tissue  builders  than  proteins.  But  we  must  not  give 
them  at  the  expense  of  other  foods.  It  is  unnecessary,  even  dangerous, 
to  give  more  proteins  than  is  required  for  repairing  the  tissues;  other- 
wise it  is  likely  to  prove  more  disastrous  than  to  a  healthy  individual. 
These  evils  are,  as  the  researches  of  Chittenden,  Mendel,  Folin,  Herter, 
Metchnikoff,  Tissier,  Combe,  Kellogg,  Turk,  and  others  show:  (1) 
that  protein  which  is  not  used  for  tissue  building  is  not  "burned  clean," 
as  are  fat  and  carbohydrates,  which  yield  merely  water  and  carbon 
dioxide,  but  leave  behind  "clinkers"  in  solid  form — for  instance,  uric 
acid;  (2)  that  meat  proteids  also  contain  such  "clinkers"  in  their 
extractives,  which  are  superadded  to  the  similar  products  from  the 
metabolism  of  proteins  in  the  body;  (3)  that  all  protein  which  is  not 
absorbed  is  subject  to  putrefaction  in  the  intestinal  canal,  and  gives 
rise  to  toxins  which  are  partially  absorbed,  and  produce  injuries  of 
various  kinds  to  the  organism  (Irving  Fisher). 

Milk. — Milk  has  been  considered  for  centuries  a  good  food  for 
consumptives — ^Aretseus  already  spoke  of  it  in  this  connection.  It 
contains  more  than  10  per  cent,  of  nutritive  matter,  albumin,  fat, 
sugar,  and  salts.  But  this  does  not  mean  that  it  is  good  to  use  it 
exclusively  for  our  patients  as  has  been  done  in  the  well-known  "milk 
cures."  If  we  wanted  to  supply  all  the  requirements  of  a  patient  it 
would  be  necessary  to  make  him  ingest  five  to  seven  quarts  of  milk 
per  day.  In  a  few  weeks  his  stomach  would  be  dilated  two  or  three 
times  its  normal  dimensions. 

But  with  other  foodstuffs  it  is  excellent  because  its  nutritive  prin- 
ciples are  easily  digestible  in  the  stomach  and  intestines,  and  it  contains 
no  toxic  substances.  It  is  just  as  good  for  a  patient  with  fever  as 
for  one  who  is  afebrile. 

It  is  best  given  between  meals  in  the  form  of  drink  and  may  be 
added  to  many  other  foods,  especially  cereals.  But  it  must  not  be 
abused;  patients  who  gorge  themselves  excessively  with  milk  lose 
their  appetite  for  other  foods.  Between  a  pint  and  a  quart  of  milk 
per  day  is  to  be  considered  the  maximum  for  the  average  patient. 

There  are  patients  who  do  not  bear  milk  very  well.  In  some  it  pro- 
vokes lactic  and  butyric  acid  fermentation  in  the  stomach;  this 
viscus  becomes  dilated  and  the  complicating  hyperchlorhj'dria  favors 
spasmodic  contraction  of  the  pylorous.  In  others,  the  milk  clots 
excessively  in  the  stomach,  large  solid  curds  are  formed  which  irritate 
the  mucous  membrane  and  cause  nausea  and  vomiting.  In  some 
patients  the  milk  passes  the  stomach  without  difficulty,  but  it  pro- 
duces trouble  in  the  intestines — gaseous  distention  and  diarrhea.  I 
have  seen  many  cases  of  diarrhea  in  consumptives,  which  were  thought 


520  DIETETIC   TREATMENT 

to  have  been  caused  by  intestinal  ulcerations,  but  which  disappeared 
with  the  withdrawal  of  milk  from  the  diet. 

The  milk  may  be  rendered  more  digestible  by  diluting  it  with  alka- 
line waters,  or  lime  water,  but  then  the  total  quantity  consumed  must 
be  reduced.  It  is  usually  more  easily  digested  when  given  with  some 
cereal,  like  oatmeal  or  rice.  Atwater  found  that  milk  is  more  easily 
digested  when  it  is  part  of  a  mixed  diet.  When  consumed  alone  the 
proportion  digested  was:  proteins,  91.2  per  cent.;  carbohydrates, 
86.3  per  cent.;  and  fat,  92.8  per  cent.  When  milk  and  bread  made 
up  the  diet,  the  amount  digested  was:  proteins,  97.1  per  cent.; 
carbohydrates,  98.7  per  cent.;  and  fat,  95  per  cent. 

Fermented  milk  is  often  more  easily  borne  in  large  quantities  when 
the  pure  article  is  not  sustained.  We  may  try  koumiss,  keffir,  or  the 
various  preparations  of  buttermilk  which  are  at  present  supplied  by 
most  milk  dealers  at  reasonable  prices,  or  may  be  prepared  at  home 
with  cultures  or  tablets  of  lactic  acid  bacilli. 

Cheese  is  an  excellent  food  for  consumptives.  But  we  should  avoid 
the  highly  seasoned  varieties.  Cream  cheese  and  ordinary  pot  cheese 
contain  considerable  nutritive  elements  and  do  not  provoke  cough  or 
gastric  irritation. 

Eggs. — Eggs  are  considered  an  excellent  food  for  tuberculous  patients 
by  the  profession  and  the  laity.  In  assimilability  they  exceed  any 
known  food  excepting  milk  and  oysters.  It  has  been  found  that  raw 
eggs  make  no  demand  on  the  stomach  and  may  pass  through,  hardly 
altered,  into  the  duodenum.  They  contain  enormous  quantities  of 
albumen  and  fat.  The  white  of  an  egg  consists  of  pure  protein  which 
is  as  digestible  and  nourishing  as  that  of  beef;  the  yolk  contains  25 
per  cent,  of  fat,  15  per  cent,  of  protein,  and  also  nuclein,  lecithin, 
iron,  and  salts.  Eating  one  dozen  eggs  per  day,  a  consumptive 
could  feed  himself,  and  pushing  it  to  twenty  eggs  he  would  absorb 
the  equivalent  of  two  and  a  half  pounds  of  beef,  because  an  egg  of 
50  grams  is  equivalent  to  about  35  grams  of  moderately  fat  beef,  or 
128  grams  of  cow's  milk.  In  other  words,  they  contain  over  700 
calories  per  pound;  the  whites  yield  250  and  the  yolks  1700  calories 
per  pound.  But  an  exclusive  egg  diet  is  just  as  bad  as  an  exclusive 
meat  diet.  Too  much  fat  is  introduced  into  the  stomach  and  con- 
gestion of  the  liver  is  the  result,  w^hile  with  an  exclusive  meat  diet, 
congestion  of  the  kidneys  occurs. 

In  my  experience  it  makes  little  difference  in  what  form  eggs  are 
given  to  consumptives  with  good  digestive  functions,  but  I  discourage 
them  from  ingesting  a  half  to  one  dozen  raw  eggs  a  day  as  some  are 
apt  to  do.  The  mode  of  preparation  has  no  influence  on  the  digest- 
ibility of  eggs,  excepting  that  when  hard  boiled  they  remain  somewhat 
longer  in  the  stomach. 

Those  who  suffer  from  derangement  of  the  function  of  the  stomach 
and  the  liver  do  not  bear  eggs  very  well  and  they  may  have  to  be 
discarded.     The  same  is  true  of  patients  who  have  an  idiosyncracy 


FATS  521 

to  eggs  and  get  colicky  pains  in  the  abdomen,  vomiting  or  diarrhea 
from  an  egg. 

Four  to  six  eggs  per  day  is  about  the  maximum  which  a  patient 
should  be  allowed,  if  we  are  to  retain  the  functions  of  the  stomach 
and  liver.    In  most  cases  less  should  be  given. 

Fats. — While  the  amount  of  fat  necessary  for  the  average  consump- 
tive has  been  exaggerated  by  many  authors,  it  is  nevertheless  a  fact 
that  a  diet  containing  a  surplus  of  easily  assimilated  fat  is  the  best. 
It  must,  however,  be  borne  in  mind  that  the  capacity  for  digesting 
and  assimilating  fat  varies  with  the  individual.  In  some  patients 
an  increase  in  the  amount  of  fat  is  immediately  followed  by  gastro- 
intestinal disturbances.  Many  people  cannot  digest  fat  meats  like 
bacon,  ham,  etc.  We  have  already  mentioned  that  many  patients 
have  shown  intolerance  for  fat  even  before  the  onset  of  the  disease. 

I  have  found  that  butter  is  superior  for  our  purposes  and  it  has  given 
me  results  as  good  as  cod-liver  oil  which  has  been  popular  for  centu- 
ries. I  direct  my  patients  to  cut  their  bread  in  thin  slices  and  cover 
them  with  heavy  layers  of  butter;  mixing  butter  with  mashed  potatoes 
and  other  foods.  As  much  as  six  to  eight  ounces  of  butter  can  thus 
be  consumed  daily  by  the  average  patient  without  gastric  or  intestinal 
disturbances.  Those  who  like,  and  can  consume,  large  quantities  of 
unskimmed  milk  may  get  the  greater  part  of  their  fat  in  this  manner, 
while  cream  and  certain  kinds  of  cheese  are  also  rich  in  fat.  In  look- 
ing for  sources  of  easily  digestible  fat  we  must  not  forget  fish:  Sal- 
mon, pompano,  sardines,  shad,  fish  roe,  caviar,  etc.,  are  very  good 
for  this  purpose.  Those  who  have  great  tolerance  for  fat  may  also 
take  in  addition  to  butter,  cream,  cream  cheese,  fat  meat,  and  bacon. 

The  quantity  of  fat  a  patient  should  consume  varies  according  to 
the  season,  the  kind  of  food  he  has  been  accustomed  to  eat,  his  toler- 
ance of  fat  and  the  condition  of  his  gastro-intestinal  tract.  Of  course, 
those  who  are  obese,  and  they  are  not  rare  among  quiescent  cases, 
should  be  discouraged  from  eating  an  excessively  fat  diet. 

It  has  been  my  experience  that  a  patient  without  preexisting  gastric 
disease  can  consume  six  ounces  of  fat  every  day  for  months  with  bene- 
fit. But  now  and  then  one  is  met  who  shows  a  decided  inclination  to 
fat  intolerance.  It  is  my  impression  that  in  most  cases  it  is  due  to  the 
excessive  amounts  of  improper  fats  which  have  been  forced  upon 
them.  It  has  been  suggested  by  Tibbies  that  when  a  patient  cannot 
take  fat,  the  proteins  can  be  increased;  100  grams  of  proteins  will 
yield  40  grams  of  fat.  Proteins  alone  will  never  fatten  a  patient; 
6.5  pounds  of  lean  meat,  or  5.5  pounds  of  lean  and  fat  meat  would  be 
required  to  supply  the  daily  requirements  of  carbon  for  an  ordinary 
person;    therefore  some  other  source  for  carbon  must  be  found. 

We  must  guard  against  quick  fattening,  "stuffing,"  of  tuberculous 
patients.  Often  consumptives  are  urged  to  eat  plenty  and  some  ingest 
enormous  quantities  of  food  and  gain  remarkably. well.  Taking  their 
weight  weekly,  and  finding  that    it    keeps  on    increasing,  they  are 


522  DIETETIC  TREATMENT     ■ 

V 

encouraged  to  continue  in  this  manner  and  at  the  end  of  three  or  four 

months  the  gain  may  be  as  much  as  thirty  or  even  forty  pounds.  But 
to  their  dismay  they  have  not  been  rehabihtated  in  other  respects; 
they  are  as  yet  unable  to  work  and  are  in  fact  weaker  than  before. 
The  weight  they  have  put  on  is  only  an  added  burden,  which  is  not 
only  useless  but  incapacitating.  In  addition,  they  suffer  from  annoy- 
ing dyspnea.  Physical  examination  shows  that  the  process  in  the  lungs 
has  not  improved;  perhaps  it  has  distinctly  extended.  Carefully  and 
guardedly  reducing  these  patients  has  often  been  of  great  benefit. 

Carbohydrates. — In  the  eagerness  to  supply  the  body  of  the  patient 
with  proteins  and  fat,  carbohydrates  must  not  be  neglected  from  the 
diet.  They  are,  as  a  rule,  easily  digested  and  assimilated,  and  they 
spare  the  proteins,  thus  maintaining  the  nitrogenous  balance  or 
equilibrium  with  smaller  quantities  of  albuminoids.  The  best  sources 
of  carbohydrates  are  potatoes,  cereals — like  oatmeal,  rice,  etc.,  which 
may  be  taken  with  milk  or  cream — pastries,  and  above  all,  bread. 
Cane  sugar  and  maple  sugar,  which  enter  into  various  culinary  prepar- 
ations, are  of  great  value.  Daremberg,^  however,  objects  to  excessive 
consumption  of  sweets  by  consiunptives  because  they  are  usually 
dyspeptics  who  do  not  stand  it  very  well.  He  says  that  those  who 
can  take  an  excessive  quantity  of  sugar  may  become  fat  rapidly; 
but  this  fattening  is  not  lasting,  just  as  the  fattening  obtained  from 
an  excessive  milk  diet.  The  best  fattening  is  obtained  from  a  mixed 
diet.  However,  there  is  no  reason  against  eating  sweet  desserts,  or 
even  candies  in  moderate  quantities,  provided  they  are  taken  after 
meals. 

Salts. — ^Mineral  salts  must  not  be  neglected.  Even  if  the  theory  of 
demineralization  is  not  well  founded,  there  is  no  question  that  the 
loss  of  mineral  salts  is  higher  among  consumptives  than  in  healthy 
individuals.  Iron,  lime,  soda,  magnesia,  and  the  phosphates  are  best 
supplied  by  such  foods  as  bread,  flour,  oatmeal,  rice,  sago,  tapioca, 
fresh  vegetables,  and  fruits.  All  these  may  be  given  plain,  or,  better 
still,  in  A'arious  other  culinary  preparations. 

Condiments. — For  their  local  appetizing  effects,  condiments,  acting 
as  they  do  as  great  salivary  and  gastric  stimulants,  may  be  taken, 
especially  by  those  who  suffer  from  anorexia.  Some  condiments,  like 
mustard  and  garlic,  contain  allyl  which  assists  in  the  digestion  of  fats, 
and  is  said  to  be  bactericidal  in  the  intestinal  tract.  At  one  time 
garlic  was  considered  a  good  remedy  against  tuberculosis.  Its  active 
principle,  allyl,  was  even  administered  subcutaneously. 

Dangers  of  Overfeeding. — While  the  majority  of  patients  stand  a 
moderate  increase  in  the  quantity  of  food  fairly  well,  there  are  many 
who  are  decidedly  harmed  by  it.  This  is  especially  seen  in  those 
who  have  been  unreasonably  induced  to  increase  the  quantity  of 
protein  foods,  such  as  eggs,  meat,  etc.,  thus  imposing  an  excessive  and 

'  Loc.  cit,  p.  1.57. 


DIETARIES  523 

often  dangerous  burden  upon  the  liver,  kidneys,  etc.  In  some  cases 
we  find  that  these  organs  have  been  decidedly  crippled  by  such  a  diet. 

The  symptoms  produced  by  excessive  protein  consumption  are 
unmistakable:  The  patient  is  drowsy  for  an  hour  or  two  after  meals, 
has  headache  and  is  irritable.  At  night  he  is  restless  and  sleepless, 
or  his  sleep  is  disturbed  by  frightful  dreams.  The  abdomen  is  dis- 
tended, the  liver  enlarged,  and  may  be  tender  on  palpation,  and  he 
has  heartburn.  Anorexia,  bilious  vomiting  and  diarrhea  are  often 
seen.  Cardiac  palpitation  and  nightsweats  are  at  times  due  to  the 
indigestion  thus  induced.  Because  of  the  plethoric  condition,  the 
patients  often  have  epistaxis  and  also  hemorrhoids  which  contribute 
to  their  misery.  The  urine  contains  albumin,  biliary  pigments, 
indican,  and  glycosuria  is  not  rare.  Arthralgic  pains  in  the  joints  are 
often  the  result  of  superalimentation.  Older  clinicians,  believing 
that  there  exists  an  antagonism  between  the  gouty  and  phthisical 
diatheses,  urged  excessive  nitrogenous  diet  combined  with  wines, 
with  a  view  of  inducing  sclerotic  changes  in  the  diseased  lungs.  On  a 
similar  principle,  the  excessive  consumption  of  alcohol  was  advised 
in  former  days.  The  acneiform  eruptions  on  the  skin  of  some  tuber- 
culous patients  are  very  frequently  due  to  the  excessive  protein  foods 
which  they  consume. 

When  overfeeding  a  patient  we  must  watch  out  for  the  following 
danger  signals:  Failure  of  appetite  and  symptoms  of  flatulent  dys- 
pepsia; dyspnea  on  exertion  which  is  obviously  not  due  to  the  tuber- 
culous toxemia  or  the  lung  lesion;  diarrhea,  and  at  times  vomiting. 
If  these  symptoms  are  not  heeded  and  forced  feeding  is  continued, 
irreparable  damage  may  be  done,  the  sheet-anchor  of  the  patient, 
his  power  to  digest  food,  is  damaged,  and  his  chances  of  recovery  are 
materially  lessened.  But  this  should  not  deter  us  from  trying  to  feed 
the  tuberculous  patient  generously.  "Excessive  feeding  is  clearly  a 
vastly  better  method  of  treatment  than  underfeeding,  for  it  at  least 
ensures  the  consumptive  taking  enough  to  repair  his  waste  and  to 
restore  his  normal  power  of  resistance  and  recuperation,"  say  Bards- 
well  and  Chapman, '^  "The  point  to  realize  is,  that  it  is  quite  an  unneces- 
sary hardship  for  patients  to  be  overfed,  and  that  it  may  do  positive 
harm." 

When  these  harmful  results  of  unwise  feeding  are  borne  in  mind, 
unfortunate  patients  will  not  be  forced  to  ingest  large  quantities  of 
food  which  may  be  excessive  and  dangerous  to  healthy  persons.  Espe- 
cially careful  must  we  be  with  plethoric,  obese,  and  sedentary  con- 
sumptives. A  dilated  stomach  which  does  not  empty  itself  with  ease 
and  promptness  is  particularly  to  be  spared.  The  dangers  of  excessive 
fat  consumption  have  already  been  dwelt  upon. 

Dietaries. — From  what  has  been  said  it  is  obvious  that  it  is  not 
necessary  to  give  detailed  dietaries  for  consumptives.    When  we  aim 

1  Diets  in  Tuberculosis,  London,  1908,  p.  49. 


524  DIETETIC  TREATMENT 

at  variety  as  the  first  requirement  for  a  good  diet,  it  would  be  neces- 
sary to  give  at  least  thirty  menus  to  suit  the  average  case.  We  will, 
therefore,  merely  mention  some  of  the  foods  which  may  be  utilized  in 
attempts  at  feeding  phthisical  patients  properly.  It  will  be  noted 
that  they  may  eat  nearly  everything  a  healthy  person  can,  as  long  as 
their  malady  is  not  complicated  by  conditions  which  alter  matters. 

Breakfast. — Milk,  coffee,  chocolate,  cocoa,  or  tea.  Bread,  butter, 
cream,  eggs,  bacon,  ham,  ox  tongue,  fish  (fresh  or  canned),  fruits  of 
any  kind.    Plenty  of  butter.     Cereals  of  any  kind. 

Lunch. — -Fish,  or  entree;  meats  (roasts,  chops,  steaks,  etc.),  poultry, 
vegetables,  custards,  puddings,  cheese,  milk,  coffee,  fruit. 

Dinner. — Soups,  meats,  poultry,  game,  fish,  all  vegetables,  puddings, 
pastries,  etc.,  cheese,  ice  cream,  coffee,  milk  or  chocolate. 

Without  going  into  details  of  the  various  dishes  that  may  be  prepared 
by  a  good  cook  who  knows  the  likes  and  dislikes  of  the  patient,  it  can 
be  stated  that  there  is  no  dish  which  is  contra-indicated  in  uncom- 
plicated phthisis.  A  good  cook  can  do  more  for  the  patient  than  all 
the  dietaries  which  may  be  printed  in  a  book. 

Betw^een  the  main  meals  there  may  be  allowed  a  light  luncheon 
between  the  early  breakfast  and  the  lunch,  consisting  of  a  glass  of 
milk  and  some  biscuit.  Some  are  allowed  an  egg  or  two  at  that  time, 
made  in  some  fortn  of  punch,  taken  raw,  or  in  any  style,  provided  it 
is  well  borne.  Similarly,  at  about  4  p.m.  tea,  coffee,  or  milk  may  be 
allowed  with  some  biscuit,  etc.  At  night  before  retiring,  a  cup  of  milk 
with  some  crackers  is  beneficial  for  some  patients.  It  will  be  noted 
that  in  this  manner  the  patient  may  have  his  milk — about  one-half 
to  one  quart  per  day — mainly  outside   of  his  mealtime,  as  drinks. 

It  must  be  emphasized  again  that  these  foods  should  be  palatably 
prepared  and  rendered  digestible  by  proper  cooking.  Otherwise 
trouble  may  arise.  The  quantity  to  be  ingested  depends  on  the  per- 
sonal equation  of  the  patient,  although  in  some  cases  matters  may 
be  forced  for  some  time  when  indicated,  but  this  should  only  be 
done  bearing  in  mind  the  contra-indications  which  have  already 
been  discussed. 


CHAPTER  XXXVI. 
MEDICINAL  TREATMENT. 

Importance  of  Medicinal  Treatment. — The  disrepute  of  medicinal 
substances  in  phthisis  during  recent  years  is  due  to  several  causes.  The 
first  and  most  important  is  that  we  have  no  specific  botanical,  chem- 
ical or  physical  agent  which,  when  administered  to  a  consumptive, 
will  exert  a  selective  action  on  the  tubercle  bacilli,  as  mercury  and 
salvarsan  do  on  the  spirocheta  of  syphilis  and  quinine  on  the  malarial 
parasite.  Nor  have  we  a  therapeutic  agent  which  will  enhance  the 
resistance  of  the  tissues  against  the  ravages  of  the  tubercle  bacilli, 
or  neutralize  their  poisons,  or  stimulate  sclerosis  of  the  affected  area. 
But  here  we  are  in  about  the  same  position  as  when  dealingwith  anemia, 
typhoid,  pneumonia,  rheumatism,  etc.  When  we  find  that  the  salicyl- 
ates relieve  the  more  painful  symptoms  of  rheumatism,  and  that 
iron  increases  the  hemoglobin  content  of  the  erythrocytes  in  chlorosis, 
that  digitalis  increases  the  force  of  the  cardiac  muscle,  we  use  these 
drugs  although  we  know  that  digitalis  does  not  regenerate  destroyed 
heart  valves,  and  salicylates  do  not  remove  the  essential  cause  of 
acute  articular  rheumatism.  Similarly  if  we  find  that  creosote,  arsenic, 
ichthyol,  etc.,  have  a  beneficial  influence  on  some  of  the  annoying 
clinical  phenomena  of  phthisis,  though  they  do  not  cure  the  disease, 
we  must  not  discard  them  merely  because  they  do  not  remove  the 
cause  of  tuberculosis,  or  kill  the  bacilli  within  the  body,  or  neutralize 
the  tuberculous  poisons,  etc. 

There  is  another  aspect  to  be  considered  in  this  connection.  Ex- 
cepting the  chosen  few,  who  have  sufficient  means  to  pay  for  first-class 
sanatorium  treatment  and  inclination  to  remain  in  the  institution  for 
months  and  perhaps  years,  the  bulk  of  the  patients  must  be  treated 
in  their  homes.  Even  if  they  get  a  few  months  of  sanatorium  treat- 
ment in  a  public  institution,  they  must  be  treated  in  dispensaries 
or  b}'  their  family  physicians  before  admission  and  after  discharge. 
The  patient  is  a  human  being;  and  when  we  consider  the  human 
element  we  find  that,  as  a  rule,  he  has  no  confidence  in  a  physician 
who  has  no  remedy  for  his  ailment.  The  dictum  "plenty  of  fresh 
air,  milk,  and  eggs,"  he  believes  he  knows  as  well  as  the  physician. 
If  his  medical  advisor  will  not  prescribe  for  him,  he  will  seek  remedies 
from  another  who  is  more  obliging  in  this  respect,  or  from  an  advertis- 
ing quack.  This  is  not  only  true  of  the  ignorant,  but  also,  almost  to 
the  same  extent,  of  the  supposedly  intelligent  patient. 

It  cannot  be  denied  that  in  many  respects  medicaments,  properly 
administered,  act  by  psychic  suggestion.     But  so  do  the  minute  and 


526  MEDICINAL   TREATMENT 

detailed  directions  given,  often  in  writing,  about  diet,  rest,  exercise, 
sleep,  etc.,  in  institutions.  "Medicinal  agents,"  says  G.  Kiiss,^  one 
of  the  most  ardent  advocates  of  tuberculin  treatment  in  France, 
"no  matter  in  what  they  consist,  always  inspire  confidence  in  the 
physician;  without  them  he  is  helpless.  ]\Ioreover,  by  giving  the  pa- 
tient in  addition  to  other  treatment,  a  prescription  calling  for  some 
medicine,  we  m.ay  succeed  better  in  our  attempts  at  keeping  him 
away  from  the  alluring  advertisements  of  charlatans  who  very  often 
impose  on  him." 

Harmless  Medication. — The  reasons  why  medicinal  agents  have 
fallen  into  disrepute  in  medical  literature — by  no  means  in  the  practice 
of  the  vast  majority  of  physicians — are  manifold.  But  the  most  im- 
portant is  perhaps  the  fact  that  drugs  have  been  abused.  "  I  regard 
medication  as  indispensable  in  the  treatment  of  tuberculosis,"  says 
Renon.^  "It  has  an  undoubted  good  effect  on  the  disease  in  general 
and  an  enormous  psychic  effect.  But  there  is  one  important  condi- 
tion which  must  be  realized  above  all  when  giving  drugs  to  consump- 
tives— they  musi  he  harmless.''  He  illustrates  this  point  by  the  fol- 
lowing instance:  Some  years  ago  the  acetate  of  thallium  was  suggested 
as  an  excellent  remedy  against  the  nightsweats  of  phthisis  and  a  trial 
showed  that  it  did  control  this  symptom  very  well  indeed.  But  it 
also  had  another  effect:  It  caused  the  hair  to  fall  out  and  the  nails 
to  shed.  The  patients  stopped  sweating,  but  incidentally  lost  their 
hair  and  nails,  which  was  a  good  reason  for  resentment.  That  certain 
drugs  used  in  phthisiotherapy  may  have  disastrous  effects  in  addition 
to  their  influence  on  the  disease  or  some  of  its  symptoms,  must  always 
be  borne  in  mind.  In  fact  it  has  been  stated  with  considerable  truth 
that  50  per  cent,  of  the  dyspepsia  in  phthisical  patients  is  due  to 
improper  medication. 

"False  Specifics." — It  is  absurd  to  banish  drugs  from  the  arma- 
mentarium of  the  physician  because  they  are  "false  specifics."  As 
if  true  specifics  are  plentiful  in  other  diseases.  It  is  curious  that 
those  who  label  creosote,  arsenic,  and  the  iodides  as  false  specifics, 
and  urge  specific  treatment  in  the  form  of  tuberculin,  are  in  one 
breath  stating  that  a  specific  remedy  is  yet  to  be  found.  "The  wanton 
theory  that  you  can  treat  with  medicines  and  cure  a  pneumonia  and 
typhoid  fever,"  says  Abraham  Jacobi,^  "but  not  a  case  of  tubercu- 
losis, has  taken  possession  of  the  oracular  mind  of  the  Colorado- 
ridden  exile  doctor.  He  should  know  better  and  do  better.  There 
is  a  drug  treatment  for  tuberculosis,  as  for  other  diseases,  and  he 
should  be  glad  to  avail  himself  of  it.  There  is  no  panacea,  however, 
for  tuberculosis,  as  there  is  none  for  pneumonia,  or  typhoid  fever. 
But  there  are  indications,  and  improvements  of  condition,  and  pro- 
longation of  life  and  recoveries." 

'  Gilbert  and  Carnot's  Therapeutiquc,  xxi,  594. 

-  Le  traitement  pratique  de  la  tuberculose,  Paris,  1908,  p.  110. 

3  American  Medicine,  1905,  x,  1063. 


CREOSOTE  527 

Creosote. — There  are  very  few  sufferers  from  tuberculosis  who  have 
not  been  given  creosote  at  some  period  of  their  illness.  Its  history  is 
similar  to  that  of  tuberculin.  Introduced  by  Reichenbach,  in  1830, 
it  was  given  in  very  large  doses  resulting  in  considerable  harm  to  the 
patients.  It  was  discarded  for  this  reason,  to  be  reintroduced  some 
twenty-five  years  ago,  and  ever  since  it  has  held  its  place  in  the  arma- 
mentarium of  the  physician  in  general  and  special  practice.  Its  most 
ardent  advocates  do  not  consider  it  a  specific,  but  then  those  urging 
tuberculin  are  still  looking  for  a  specific  for  tuberculosis.  In  the  hands 
of  those  who  have  administered  it  intelligently  it  has  proved  the  best 
medicinal  agent  to  relieve  some  of  the  most  baneful  symptoms  of  the 
disease. 

When  administered  in  the  proper  cases  and  in  proper  dosage,  it 
improves  the  appetite,  stimulates  digestion  and  assimilation,  improves 
nutrition,  diminishes  expectoration,  removing  at  times  its  purulent 
character  and  disagreeable  taste  and  odor,  all  of  which  is  sufficient 
of  an  encouragement  to  the  average  sufferer  from  phthisis  to  bestow 
confidence  in  the  physician  and  to  look  forward  to  an  ultimate  recovery. 
This  beneficial  action  of  creosote  is  ascribed  by  some  authors  to  its 
power  to  inhibit  the  growth,  or  destroy  tubercle  bacilli  in  the  gastro- 
intestinal tract,  which  are  inevitably  swallowed  by  every  consumptive. 
It  is  one  of  the  best  gastric  and  intestinal  antiseptics  we  have.  It 
has  been  found  that  part  of  the  ingested  drug  is  excreted  by  the 
bronchial  mucous  membrane  and,  while  it  cannot  be  expected  to 
destroy  the  bacilli  in  the  lungs — hardly  any  drug  could  reach  the 
avascular  tubercle,  even  if  it  could  be  given  in  sufficiently  large  doses — 
it  exerts  there  a  beneficial  influence  as  is  evidenced  by  the  decrease 
in  the  amount  of  sputum  brought  out,  and  the  diminution  in  the 
intensity  of  the  associated  bronchitis,  laryngitis,  and  tracheitis. 

It  is  a  peculiar  fact,  not  generally  appreciated,  that  creosote  often 
provokes  general  and  local  reactions  which  are  analogous  to  those 
provoked  by  tuberculin.  Usually  with  excessive  doses,  but  occasion- 
ally also  with  minimal  doses,  after  taking  creosote  for  several  days 
the  patient  is  overtaken  by  a  feeling  of  chilliness  and  fever,  pain  in 
limbs,  back,  and  joints,  weakness,  fatigue,  and  insomnia.  jNIalaise, 
gastric  disturbances  and  even  vomiting,  in  patients  whose  stomach 
has  heretofore  not  given  any  trouble,  now  make  their  appearance. 
The  part  of  the  creosote  eliminated  through  the  bronchial  mucous 
membrane  often  excites  a  focal  reaction  which  at  times  reminds  one 
of  the  focal  reaction  of  tuberculin.  Of  course  in  the  case  of  tuberculin 
a  single  dose  is  often  enough  to  produce  this  reaction,  while  in  the 
case  of  creosote  it  is  only  the  more  or  less  prolonged  administration 
that  is  apt  to  produce  this  effect.  In  such  cases  sanguineous  expectora- 
tion and  even  hemorrhage  is  not  uncommon,  while  the  lesion  in  the 
lung  may  be  aggravated  or  even  spread.  Rales,  which  were  previously 
absent  or  scanty,  now  make  their  appearance  and  the  general  aspect 
of  the  patient  is  aggravated. 


528  MEDICINAL   TREATMENT 

If  the  administration  of  creosote  is  persisted  in  after  these  symp- 
toms, as  I  have  seen  many  times,  the  condition  of  the  patient  may  be 
aggravated  to  an  extent  as  to  render  the  prognosis  hopeless  in  a  case 
that  previously  had  a  fair  outlook.  Smoky  urine,  like  that  of  phenol 
poisoning  is  now  seen;  the  patient  complains  of  a  taste  of  creosote  in 
his  mouth.  This  may  be  followed  by  vertigo,  profuse  perspiration, 
chilly  sensations,  and  even  cyanosis  and  collapse,  as  I  have  seen  in 
one  case  which  was  greatly  relieved  by  the  discontinuance  of  the  drug. 

Gontra-indications. — Bearing  all  this  in  mind  we  can  say  that  creosote 
is  contra-indicated  in  all  cases  in  which  it  provokes  gastric  disturb- 
ances. If  after  taking  moderate  doses  of  the  drug  the  appetite  does 
not  improve,  it  should  be  discontinued.  It  is  also  contra-indicated 
in  all  febrile  cases  in  which  the  temperature  is  100°  F.  or  more,  and 
also  in  all  progressive  cases,  because  they  are  the  ones  in  which  gen- 
eral and  local  reactions  are  apt  to  be  provoked  and  spread  the  lesion 
in  the  lungs. 

Patients  subject  to  hemoptysis  must  not  be  given  any  creosote; 
even  blood-streaked  sputum  should  serve  as  a  warning  for  the  im- 
mediate discontinuance  of  the  drug.  Moreover,  one  must  not  wait 
for  the  appearance  of  smoky  urine,  but  carefully  watch  for  albumin 
which  is  often  brought  about  by  creosote.  In  general,  albuminuria  is 
a  strong  contra-indication  to  the  administration  of  creosote. 

Indications. — In  all  incipient  cases  in  which  the  appetite  is  poor  and 
digestion  defective,  creosote  may  be  given.  With  the  improvement 
in  the  nutrition  of  the  patient,  owing  to  cessation  of  gastric  and 
intestinal  fermentation,  the  local  condition  in  the  lungs  also  shows 
improvement.  In  chronic,  sluggish,  afebrile  cases  of  tuberculosis, 
especially  those  characterized  by  profuse  expectoration,  creosote  is 
often  of  immense  benefit,  if  rationally  administered.  In  addition 
to  its  good  effects  on  the  gastro-intestinal  functions,  it  also  diminishes 
the  amount  of  expectoration,  ameliorates  the  cough,  etc.,  and  with  the 
gain  in  weight  and  comfort,  it  has  an  excellent  effect  on  the  psychic 
state  of  the  patient  who  becomes  more  encouraged  and  hopeful.  In 
fibroid  phthisis,  characterized  by  profuse  expectoration  of  purulent 
material,  provided  there  is  no  concomitant  emphysema,  creosote  is 
the  best  remedy  we  have.  I  have  seen  drying  up  of  cavities,  at  least 
temporarily,  in  some  measure  due  to  the  proper  administration  of 
creosote. 

Administration. — A  good  product  must  be  used.  Soon  after  its 
introduction  creosote  fell  into  disuse  mainly  because  of  the  bad  quality 
of  the  product.  Good  creosote,  fit  for  therapeutic  administration, 
must  be  obtained  from  the  fractional  distillation  of  beech-wood  tar. 
The  product  rlispensed  in  many  pharmacies  in  this  country  is  obtained 
from  the  distillation  of  bituminous  coal  and  contains  many  imi)urities 
which  are  not  well  tolerated.  A  good  i)rei)aration  of  creosi^te  contains 
25  per  cent,  of  guaiacol,  but  many  of  the  products  dispensed  under 
this  name,  even  when  obtained  from  beech-wood,  contain  much  less. 


CREOSOTE  529 

It  is  best  administered  in  capsules  which  does  away  with  the  dis- 
agreeable odor.  Moreover,  the  mucous  membrane  of  the  stomach  and 
intestines  is  not  as  easily  injured  by  creosote  as  that  of  the  mouth  and 
pharynx,  so  that  the  disagreeable  local  effects  are  done  away  with 
through  capsules.  Some  mix  it  with  balsam  of  tolu,  and  it  is  best 
given  after  meals.  Those  who  cannot  swallow  capsules  may  take  it 
in  this  form: 

I^ — Creosoti gtt.  xxx  2.0 

Vini  pepsini giv  120.0 

M.    S. — Teaspoonful  in  water  three  times  a  day  after  meals,  gradually  increasing. 

I^ — Creosoti, 

Picis  liquidse  radicis .   aa  gr.  xxiv  1.5 

Alcoholis  absol 5iij  12.0 

Balsam,  peruv 3iv  15.0 

Tinct.  Helianthi  annul     . 3v  20.0 

Olei  terebinth,  rectificati, 

MyrthoH aa  3ij  7.5 

M.     S. — Three  times  a  day,  one  teaspoonful  in  milk  or  water  one  hour  after  meals. 

I^— Tannini 3v  20.0 

Calcii  phosphorici 3v  20.0 

Creosoti Siiss  10.0 

M. — Div.  in  part  40;    ft.  capsul. 

S. — One  capsule  three  times  a  day  after  meals. 

Beverley  Robinson  has  had  good  results  with  the  following: 

I^ — Creosoti gtt.  vj  0.5 

Glycerini Sj  25.0 

Spiritus  frumenti ad      giij  100.0 

M.     S. — Teaspoonful  in  water  three  times  a  day  after  meals. 

This  dose  may  be  increased  to  two  or  three  teaspoonfuls,  or,  if  it  is 
desired  to  increase  the  creosote,  the  amount  of  it  may  be  doubled. 
If  the  whisky  is  deemed  inadvisable,  elixir  calisaya  or  the  compound 
tincture  of  cardamom  may  be  substituted. 

Many  have  administered  creosote  by  inhlalation  and  have  obtained 
good  results.  In  this  country,  Beverley  Robinson  introduced  this 
method.  He  recommends  equal  parts  of  creosote  and  alcohol  or,  when 
there  is  much  irritative  cough,  equal  parts  of  creosote,  alcohol,  and 
spirits  of  chloroform,  on  the  sponge  of  a  perforated  zinc  inhaler.  The 
inhaler  should  be  used  frequently,  at  first  for  a  few  minutes,  later 
gradually  increasing  the  time  till  it  is  used  from  half  an  hour  to  an 
hour  at  a  time,  and  finally  it  may  be  used  almost  continually  during 
the  day  and  frequently  all  night.  "These  inhalations  modify  sputum 
favorably,  diminish  its  quantity,  lessen  cough,  thus  promoting  rest, 
sleep,  and  nutrition  and  general  improvement  physically,  and  in  some 
instances  appear  to  be  the  means  through  which  the  patient  has  gotten 
rid  of  tubercle  bacilli  permanently." 

34 


530  MEDICINAL   TREATMENT 

The  following  are  good  formulae  for  inhalation: 

^ — Creosoti gtt.  ^dj  0.5 

Tincturge  benzoini  comp giij  100.0 

M.     S. — To  inhale  a  teaspoonfiil  from  boiling  water,  three  or  four  times  a  day;  shake. 

I^ — Creosoti gtt.  vij  0.5 

Olei  pini  silvestris 3iiss  10.0 

Olei  terebinthinse        3iss  5.0 

Tincturse  benzoini  Comp giv  100.0 

M.      S. — Shake.    To  inhale  a  teaspoonfiil,  from  boiling  water  three  or  four  times  a  day. 

Derivatives  of  Creosote.- — Because  of  its  caustic  taste  and  disagree- 
able odor  creosote  is  not  well  tolerated  by  many  patients;  even  when 
given  in  capsules  the  odor  is  often  penetrating.  Guaiacol,  the  main 
active  principle  of  creosote,  can  be  given  instead,  but  it  is  insoluble 
in  water,  has  an  objectionable  odor  and  taste  and  is  a  gastric  irritant. 
There  have  been  brought  out  a  large  number  of  preparations  which 
retain  most,  or  all,  of  the  useful  qualities  of  creosote  without  its  draw- 
backs. These  derivatives  of  creosote  are  mostly  used  at  present 
with  the  same  result  as  with  the  original  drug. 

Of  these  creosote  carbonate  (creosotal)  is  perhaps  the  best.  When 
ingested  it  breaks  up  slowly  in  the  intestine,  liberating  creosote.  It 
may  be  given  in  capsules  of  5  to  10  drops  three  or  four  times  a  day. 
Many  pharmaceutical  houses  market  globules  which  are  very  elegant. 
It  may  also  be  given  to  patients  to  be  taken  in  a  certain  number  of 
drops  in  water,  milk,  or  coffee;   or  the  following  prescription  is  useful: 

I^ — Creosoti  carbonatis Biv  120.0 

Aetheris giss  5.0 

Alcoholis  sol.         3vj  25.0 

Vanilin gtt.  \'ij  0.5 

M.  S. — Fifteen  drops  in  water  or  in  milk  three  times  a  daj^  after  meals;  increased  if 
well  tolerated. 

.  In  many  cases  between  30  and  60  grains  of  creosote  carbonate  may 
be  given  per  day. 

Guaiacol  carbonate  (duotal)  is  another  preparation  which  is  very 
extensively  used.  It  may  be  given  in  powder  or  capsule  from  10  to  40 
grains  a  day,  or  combined  with  arsenic. 

Both  of  the  two  above  preparations  are  now  sold  quite  reasonably. 
But  for  those  who  can  afford  to  pay,  we  have  a  wider  range  of  choice. 
Styracol  (guaiacol  cinnamate)  contains  a  high  percentage  of  guaiacol. 
Thiocol  (potassium-guaiacol-sulphonate)  may  be  given  in  5  to  15 
grains  three  times  a  day  in  powder,  tablet,  or  capsule.  It  is  a  non- 
toxic, tasteless,  odorless  powder,  soluble  in  water.  ]Many  patients 
who  do  not  tolerate  guaiacol  take  this  preparation  very  well,  and  in 
those  who  sufl'er  from  diarrhea  it  is  to  be  preferred.  But  it  contains 
less  guaiacol  than  most  other  preparations  of  this  class  and  its  action 
is  not  as  intense  as  that  of  the  others.     In  fact,  it  is  sometimes  not 


CREOSOTE  531 

decomposed  in  the  intestines,  and  may  be  excreted  unchanged.  For 
those  who  prefer  their  medicine  in  Hquid  form  and  for  children,  it  may 
be  given  in  the  form  of  siroHn,  a  10  per  cent,  solution  of  thiocol  in 
orange  syrup,  which  may  be  given  one  to  three  teaspoonfuls  three 
times  a  day.  There  is  no  doubt  that  many  who  cannot  tolerate 
creosote  or  guaiacol  take  this  less  toxic  preparation  very  well. 
Sir  R.  Douglas  Powell  recommends  the  following: 

I^ — Guaiacol     carbonatis,     guaiacol     benzoatis     vel 

styracol 3iss  6.0 

Calcii  hypophosphatis 3ss  2.0 

Pulvis  tragacauthae  co 5j  4:0 

Misce  bene,  adde  guttatim: 

Syr.  pruni  virginianse  vel  elixir  aurantii     .       .      .  gss  16.0 

SjT.    calcii    lactophosphatis    vel  s5t.    hypophos- 

phitum  CO gj  .32.0 

Aquae  chloroformi ad  gvj  190.0 

S. — One  teaspoonfiil  in  water  or  liquid  malt  three  times  a  day  soon  after  meals. 

3 — Creosoti  carbonatis 5iv  16.0 

Tinct.  gentianse  co 5iv  16.0 

Syr.  pruni  virginianse giij  90.0 

S. — One  teaspoonful  in  a  wineglass  of  water  or  malt  extract  after  meals  three  times  a 
day.    Increase  the  dose  by  five  drops  each  second  day  up  to  two  teaspoonfuls  by  measure. 

Ichthyol. — Ammonium  sulphoichthyolate  or  ichthyol  has  been  found 
very  useful  in  many  cases  of  phthisis.  Some  authors  state  that  it  has 
a  favorable  influence  on  the  metabolism,  prevents  albuminous  decom- 
position and  favors  assimilation  of  food.  Helmers  found  that  about 
one-third  of  the  sulphur  ingested  with  ichthyol  circulates  in  the 
juices  of  the  body;  others  asserted  that  it  even  had  a  bactericidal 
action,  without  hurting  the  body  cells,  etc.  It  may,  however,  be  stated 
that  we  do  not  know  the  exact  pharmacology  of  this  preparation,  but 
that  empirically  it  has  been  found  useful  in  many  cases  of  phthisis. 

It  may  be  given  in  water  2  to  5  drops  three  tim^es  a  day,  beginning 
with  the  smaller  dose  and  gradually  increasing  according  to  tolerance. 
Because  of  its  disagreeable  odor  and  taste,  the  drops  should  be  diluted 
in  large  quantities  of  water  or  milk  and  given  before  meals.  It  may 
also  be  administered  in  black  coft'ee.  Or  the  following  formulae  may 
be  used: 

li— Ichthyolis gvj  25.0 

Aquae  distil gij  60.0 

Alcoholis  rectific gij  60.0 

Syr.  citr., 

Syr.  aurant  cort aa      giss  50.0 

M.     S. — Teaspoonful  in  water  three  times  a  day  before  meals. 

De  Renzi  says  that  the  above  formula  conceals  the  taste  and  odor 
of  ichthyol.    The  following  is  also  of  use: 

I^ — Ichthyolis 5iiss  10.0 

Syrup,  sim pi 3v  -           20. 0 

Aquae  menth.  piper giij  80.0 

M.     S. — Teaspoonful  in  a  glass  of  water  three  times  a  day. 


532  MEDICINAL   TREATMENT 

In  many  cases  ichthyol  improves  the  appetite,  diminishes  the  fre- 
quency of  the  cough  and  the  expectoration,  changing  the  latter  so  that 
its  purulent  character  vanishes.  The  general  condition  of  the  patient 
improves  with  the  improvement  in  the  nutrition.  In  some  patients 
the  remedy  disagrees,  causing  flatulence,  abdominal  pains,  diarrhea, 
loss  of  appetite,  and  eructation  of  gases.  In  fact,  as  has  been  shown 
by  Barnes  in  patients  in  whom  the  administration  of  ichthyol  does 
not  immediately  improve  the  appetite,  it  is  not  advisable  to  continue 
the  drug.  I  can  add  that  diarrhea  also  shows  that  the  drug  disagrees. 
My  patients  do  not,  as  a  rule,  mind  the  disagreeable  odor  and  taste 
when  given  well  diluted  with  water,  milk,  or  coffee. 

Ichthyol  should  be  tried  in  ever\'  case  of  phthisis  because  it  has 
not  the  dangerous  characters  of  creosote  and  arsenic  and  their  deriva- 
tives; in  fact  it  is  well  tolerated  in  most  eases;  only  gastro -intestinal 
disturbances  occasionally  preventing  its  use. 

Arsenic. — Arsenic  has  been  found  an  excellent  stimulant  of  nutri- 
tion, a  hematinic,  reconstructive,  and  alterative  in  chronic  wasting 
diseases  including  phthisis.  The  various  organic  arsenic  compounds 
recently  introduced  were  stated  to  lack  the  greater  part  of  the 
toxicity  of  arsenic  while  retaining  its  curative,  reconstructive,  and 
antiseptic  properties.  The  advocates  of  arsenic  medication  in  tuber- 
culosis claim  that  it  increases  the  appetite,  improves  assimilation  of 
food,  and  stimulates  the  blood-forming  organs  in  addition  to  its 
stimulating  effects  on  the  nervous  system.  In  short,  arsenic  is  sup- 
posed to  fortify  the  tissues  against  the  ravages  of  the  tubercle  bacilli. 

From  an  extensive  use  of  arsenic  in  phthisis  the  author  has  not 
found  that  it  exerts  any  direct  influence  on  the  tuberculous  lesion  in 
the  lungs,  even  when  administered  to  patients  who  tolerate  it.  The 
quantity  and  quality  of  the  expectoration  is,  however,  very  favor- 
ably influenced ;  purulent  sputum  often  becoming  mucous  and  greatly 
reduced  in  quantity.  With  the  improvement  in  the  appetite  and 
nutrition  a  great  deal  is  gained — the  patient  is  encouraged.  The  fever 
is,  however,  not  influenced,  nor  are  the  nightsweats.  In  fact  it  should 
not  be  given  to  febrile  patients. 

It  may  be  given  as  an  adjuvant  to  creosote  treatment  in  the  form 
of  trioxide,  as  in  the  foUowing  formula: 

I^ — Guaiacolis  carbonatis 3v  20.0 

Arsenici  trioxidi gr.  iss  0.1 

Strychninse  sulphatis gr.  j  0.06 

M.  ft.  pilullse  no.  Ix  div. 

S.— One  pill  three  times  a  day  after  meals. 

It  may  be  given  in  the  form  of  Fowler's  solution,  beginning  with 
2  or  3  drops  after  meals  and  increasing  daily  until  10  drops  are  taken 
three  times  a  day. 

During  recent  years  various  organic  compounds  of  arsenic  have  been 
used  in  phthisis,  administered  either  by  mouth  or  hypodermically. 
Of  these  the  cacodylates  of  sodium,  strychnin,  iron,  and  guaiacol  may 


lODlN  533 

be  mentioned.  Many  of  these,  as  well  as  atoxyl,  are  at  present  sold 
by  pharmacentical  houses  in  ampoules  ready  for  hypodermic  and 
intravenous  administration.  But  in  my  experience  none  of  these 
preparations  has  any  advantages  over  the  inorganic  arsenic;  the 
trioxide  and  Fowler's  solution  answer  all  requirements.  In  fact  some 
of  them,  notably  atoxyl,  are  dangerous  because  they  are  liable  to 
cause  amblyopia. 

When  administering  arsenic  to  phthisical  patients  certain  precau- 
tions are  to  be  taken.  It  should  not  be  continued,  especially  in  large 
doses,  for  more  than  a  week  or  ten  days.  Symptoms  of  intolerance 
may  make  their  appearance,  such  as  loss  of  appetite,  thirst  and  dryness 
in  the  mouth,  colicky  pains,  and  diarrhea.  In  some  cases  the  fever 
rises  as  a  result  of  large  or  even  small  doses  of  arsenic.  Tachycardia, 
cardiac  palpitation,  and  insomnia  are  occasionally  observed.  It  should 
not  be  given  to  febrile  patients,  and  to  those  showing  a  tendency  to 
hemoptysis.  In  fact,  if  during  the  administration  of  arsenic  there 
appears  streaky  sputum,  it  should  be  considered  a  danger  signal  and 
the  arsenic  is  to  be  discontinued  at  once. 

lodin. — For  generations  iodin  has  been  used  in  the  treatment  of 
scrofulous  children  with  good  results.  It  has  also  been  found  useful 
in  assisting  the  resolution  of  pleural  adhesions  and  in  the  relief  of  the 
symptoms  of  chronic  bronchitis,  pulmonary  emphysema,  and  asthma. 
That  the  iodides  have  an  effect  on  tuberculous  lesions  in  the  lungs  is 
evidenced  by  the  fact  that  small  doses  of  the  iodide  of  potassium 
may  cause,  in  persons  with  incipient  tuberculosis,  reactions  similar 
to  those  produced  by  tuberculin,  as  was  shown  by  Rondot.  In  fact 
many  authors  recommend  it  for  diagnostic  purposes,  at  least  to  pro- 
voke expectoration  which  may  be  examined  for  tubercle  bacilli.  SoreP 
found  that  tuberculous  animals,  when  given  large  doses  of  potassium 
iodide  succumb  to  generalized  miliary  tuberculosis,  and  usually  much 
earlier  than  the  controls. 

Some  French  authors  recommend  the  iodides  in  most  cases  of  pul- 
monary tuberculosis,  but  it  seems  to  be  a  dangerous  drug  for  the 
reasons  just  stated.  But  in  some  cases  of  incipient  phthisis  without 
fever  the  iodides  do  good,  especially  in  those  in  whom  the  tuberculous 
process  has  been  implanted  on  emphysematous  lungs.  This  is  also 
true  of  asthma  and  tuberculosis — the  iodides  often  control  or  relieve 
the  nocturnal  attacks  of  dyspnea.  But  one  must  always  guard  against 
giving  this  drug  to  sufferers  from  the  congestive,  inflammatory,  pro- 
gressive lesions,  and  those  subject  to  hemoptysis. 

It  is  best  given  in  a  saturated  solution  of  iodide  of  potassium  of  which 
each  drop  represents  1  grain  of  the  drug.  Small  doses  are  to  be  given 
at  first,  2  to  5  grains,  three  to  five  times  a  day.  If  no  intolerance  is 
shown  it  may  be  increased.  I  have  often  used  some  of  the  organic 
compounds  of  iodin — sajodin,  etc, — with  good  results. 

1  Ann.  de  I'lnstit.  Pasteur,  1909,  xxiii,  5.33. 


534  MEDICINAL   TREATMENT 

Succinimide  of  Mercury. — Mercury  has  been  used  in  the  treatment 
of  tuberculosis  for  many  years.  But  more  recently  Dr.  B.  L.  Wright 
developed  a  new  method  of  administering  it  and  reported  a  larger 
number  of  recoveries  than  has  been  claimed  with  any  other  medica- 
tion. He  used  the  succinimide  of  mercury  hypodermically,  in  doses 
of  J  of  a  grain  given  on  alternate  days  increasing  the  dose  guardedly 
till  the  limits  of  toleration  are  reached.  iVs  soon  as  symptoms  of 
mercurialization  appear,  or  there  is  a  rise  in  the  temperature,  anorexia, 
loss  o£ .weight,  etc.,  the  dose  is  either  reduced  or  the  treatment  is  dis- 
continued for  a  time.  In  most  cases  about  thirty  injections  are  given, 
followed  by  a  rest  of  two  weeks,  during  which  period  iodide  of  potas- 
sium may  be  administered.  A  second  series  of  injections  is  given  to 
those  who  tolerate  the  drug. 

I  have  tried  this  treatment  and  found  it  of  immense  value  in 
phthisis  complicating  syphilis,  otherwise  it  is  decidedly  harmful.  As 
was  already  stated  it  appears  that  when  tuberculosis  is  implanted  in 
a  syphilitic  subject,  the  disease  is  apt  to  run  a  very  sluggish,  chronic 
course.  Fibrosis  is  very  active.  In  these  cases  both  the  iodides  and 
mercury,  if  intelligently  and  guardedly  administered,  may  be  very 
efficacious.  The  succinimide  of  mercury  may  be  used  instead  of 
other  forms  of  the  drug.  But  the  doses  given  by  Wright  are  decidedly 
excessive — the  same  results  may  be  obtained  by  the  hypodermic 
administration  of  |  or  yV  of  a  grain  twice  weekly.  On  the  other 
hand,  salvarsan  now  offers  a  better  means  of  combating  active  syphilis 
combined  with  tuberculosis  than  the  succinimide  of  mercury. 

Hypophosphites  and  Glycerophosphates. — It  will  be  noted  that 
most  of  the  medicinal  preparations  mentioned  above  have  their  indi- 
cations and  contra-indications,  and  some  are  not  without  danger  when 
improperly  administered.  The  safest  medication  in  phthisis  appears 
to  be  the  time-honored  administration  of  the  hypophosphites.  Re- 
cently the  glycerophosphates  of  lime,  iron,  magnesium,  etc.,  have 
been  used  very  extensively  on  the  theory  that  phthisis  is  a  manifes- 
tation of  lime  starvation  and  that  recalcification  and  remineralization 
of  the  body  are  of  great  importance  in  our  efforts  at  combating  the 
effects  of  the  tuberculous  process.  There  is  no  doubt  that  in  many 
cases  of  phthisis  these  medicinal  substances  have  an  excellent  influence 
on  the  nutrition  of  the  patient  and  they  are  also  of  use  in  relieving 
the  anemia  which  is  such  a  frequent  accompaniment  of  the  disease. 
We  may  give  the  official  compound  syrup  of  hypophosphites  in  doses 
of  one  to  two  teaspoonfuls  three  times  a  day  after  meals.  The  gly- 
cerophosphites  may  be  given  in  any  form.  Pharmaceutical  houses 
have  many  elegant  and  palatable  preparations  of  glycerophosphites 
in  tablet,  capsule,  and  liquid  forms  which  may  be  used.  Their  tonic 
effects  are  beyond  question. 

Cod-liver  Oil. — Physicians  of  past  generations  bestowed  great 
confidence  in  the  therapeutic  virtues  of  cod-li\'er  oil  in  tuberculosis, 
and  many  modern  practitioners  still   consider  it  an  excellent  thera- 


COD-LIVER  OIL  535 

peutic  agent.  Some  have  ascribed  the  curative  action  of  this  oil  to 
certain  of  its  constituents.  Thus,  some  beheve  that  it  is  the  iodin 
which  is  effective,  others  see  in  the  bromin  the  active  principle.  But 
careful  chemical  analysis  has  shown  that  there  are  only  traces  of  these 
elements  in  cod-liver  oil.  The  biliary  salts,  the  hepatic  ferments, 
the  lipoids,  the  lecithin,  etc.,  have  been  stated  to  be  of  more  value 
than  the  fat  of  cod-liver  oil.  John  W.  Wells^  and  others  believe  that, 
in  addition  to  the  ready  absorption  of  the  fat  of  cod-liver  oil,  it  pos- 
sesses powers  of  increasing  the  absorption  of  other  fats  of  the  food  to 
a  marked  degree. 

The  recent  intensive  studies  of  the  internal  secretions  have  also 
thrown  some  light  on  the  action  of  cod-liver  oil  in  phthisis  according 
to  some  authors.  Thus,  Williams^  recently  stated  that  the  superiority 
of  this  oil  to  others  is  mainly  due  to  the  internal  secretion  of  the  liver 
of  the  fish,  which  "when  introduced  into  the  human  economy,  acts 
as  a  stimulant  to  one  of  the  normal  internal  secretory  glands,  and 
the  secretion  of  the  one  so  stimulated  is  inimical  to  the  development 
of  the  tubercle  bacilli."  He  believes  that  only  the  crude  oil  contains 
these  active  principles  and  is  therefore  more  efficacious  than  the 
refined  oil.  Iscovesco,^  from  his  experimental  researches,  is  con- 
vinced that  the  efficaciousness  of  cod-liver  oil  is  due  to  the  lecithides 
which  it  contains.  He  treated  a  large  series  of  animals  for  four  months. 
Those  who  got  cod-liver  oil  increased  in  weight  to  the  extent  of  55 
per  cent;  those  who  got  cod-liver  oil  from  which  the  lecithides  had 
been  removed  gained  only  27  per  cent.;  those  who  were  given  olive 
oil  gained  33  per  cent.;  others  were  given  oil  to  which  was  added  0.5 
yro  mille  of  the  lecithides  extracted  from  cod-liver  oil  and  they  gained 
56  per  cent.  The  control  animals  gained  only  29  per  cent.  Williams 
and  Forsyth*  claim  that  the  unsaturated  fatty  acids  of  cod-liver  oil 
tend  to  disintegrate  the  waxy  envelope  of  the  tubercle  bacilli,  thus 
destroying  them. 

These  theories  are  interesting,  and  deserve  further  study,  but  there 
is  no  doubt  that  cod-liver  oil  is  an  important  remedy  in  tuberculosis, 
even  if  only  for  the  fact  that  it  contains  a  considerable  proportion  of 
easily  assimilable  fat,  and  it  may  be  used  as  a  food  rather  than  as  a 
drug.  Patients  who  do  not  take  animal  fats  like  butter,  etc.,  are 
distinctly  benefited  by  cod-liver  oil. 

Cod-liver  oil  should  be  given  in  large  doses;  to  some  patients  as 
much  as  2  ounces  per  day  may  be  given  and  some  French  authors,  like 
Jaccound,  Grancher,  and  Daremberg,  have  given  more  than  4  ounces 
per  day  Some  apparently  have  a  marked  tolerance  for  this  prepara- 
tion, and  they  may  utilize  it  instead  of  superalimentation.  On  the  other 
hand,  there  are  patients  who  cannot  tolerate  it,  and  even  small  doses 

1  British  Med.  Jour.,  1902,  ii,  1222. 

2  Practitioner,  1911,  Ixxxviii,  605. 

3  Compt.  Rend.  Soc.  Biol.,  1914,  Ixxvi,  34. 
*  Brit.  Med.  Jour.,  1909,  ii,  1120. 


536  MEDICINAL   TREATMENT 

cause  eructations,  nausea,  and  oily  taste  in  the  mouth.  Diarrhea  is 
another  of  the  untoward  effects  in  some  who  do  not  bear  the  oil  very 
well. 

Indications. — Cod-liver  oil  is  indicated  in  all  afebrile  cases  of  phthisis. 
All  patients  who  willingly  take  it,  and  digest  it  well  in  large  doses, 
should  be  given  this  oil,  without  incidentally  curtailing  their  usual 
amount  of  other  nourishment.  It  may  be  continued  for  a  long  period 
of  time;  as  long  as  the  patient  is  apparently  benefited  by  it  and  his 
digestive  functions  remain  normal,  the  appetite  is  good  and,  above 
all,  there  is  no  diarrhea.  Patients  with  fever  do  not  tolerate  it  as 
well  as  those  who  have  no  p^Texia.  Children  with  tendencies  to 
scrofula,  with  enlarged  tuberculous  glands,  especially  tracheobronchial 
adenopathy,  and  who  are  as  a  result  underfed  and  anemic,  often 
derive  great  benefit  from  cod-liver  oil.  It  appears  that  children  take 
it  with  greater  ease,  and  more  often  with  distinct  benefit,  than  adults. 

Contra-indicaticns. — Cod-liver  oil  is  contra-indicated  in  cases  in 
which  the  pjatients  do  not  tolerate  it  in  even  small  doses.  The  best 
criteria  are  the  state  of  the  appetite  and  digestion.  As  soon  as  these 
are  deranged,  it  should  be  discontinued. 

Administration. — As  long  as  we  consider  cod-liver  oil  merely  a  fat 
food,  and  disregard  its  other  constituents,  it  is  best  to  administer  it 
in  as  palatable  a  form  as  possible.  In  former  times  the  crude  oil,  a 
product  of  decomposition  of  the  livers  of  the  cod,  was  used.  Some 
modern  authors  even  now  insist  that  this  form  is  most  beneficial  for 
phthisical  patients.  But  it  has  a  very  disagreeable  odor  and  taste  and 
it  requires  courage  on  the  part  of  the  patient  to  swallow  it.  It  is  also 
apt  to  cause  indigestion,  eructations,  diarrhea,  etc.  The  light,  or 
amber-colored  oil,  prepared  by  melting  fresh  livers  by  a  steam  process, 
is  less  disagreeable  and  more  easily  tolerated.  It  should  at  first  be 
given  in  small  doses  of  the  Norwegian,  light-colored  oil,  and  in  case 
the  gastrointestinal  tract  tolerates  it,  the  dose  is  to  be  increased  so 
that  within  a  few  weeks  the  patient  takes  four  to  six  tablespoonfuls 
a  day  after  meals.  It  should  not  be  forced  on  patients;  when  they 
refuse  to  take  it,  or  it  causes  nausea,  eructations,  diarrhea,  etc.,  it 
should  be  discontinued. 

It  is  best  that  the  pure  oil  should  be  given  and  many  patients  take 
it  easily.  ^Yith  some  the  odor  and  taste  have  to  be  masked,  and  this 
may  be  done  in  the  following  manner:  It  may  be  given  in  orange 
juice,  or  in  some  volatile  oil.  Many  patients  take  it  with  ease  in  coffee 
or  milk.  A  pinch  of  salt  placed  in  the  mouth  before  taking  it  may  dis- 
guise the  taste.  Those  who  are  allowed  to  take  alcohol  may  take 
some  whisky  or  brandy  into  the  mouth  where  it  is  kept  for  a  few 
seconds  without  swallowing,  and  then  the  oil  is  taken.  Some  use 
peppermint-water  or  tomato  ketchup  for  the  purpose,  or  orange-  or 
lemon-juice.  The  difficulties  owing  to  the  odor  and  taste  are  over- 
come soon  in  most  patients,  and  they  take  it  freely. 

The  various  emulsions  offer  no  adNantage  over  the  pure  oil.     If 


COD-LIVER  OIL  537 

they  contain  the  indicated  percentage  of  the  oil,  they  are  as  dis- 
agreeable as  the  pure  article,  and  one  who  can  take  an  emulsion,  can 
take  and  digest  the  oil.  The  various  preparations  and  "extracts" 
which  are  alleged  to  have  all  the  therapeutic  qualities  of  cod-liver 
oil  without  any  of  its  disadvantages,  have  been  found  worthless, 
lacking  as  they  do  the  fatty  substances  which  are  of  value  for  the 
nutrition  of  the  patient.  On  the  other  hand,  many  of  the  preparations 
of  cod-liver  oil  and  malt,  hypophosphites,  creosote,  etc.,  may  be 
utilized  in  the  treatment  of  phthisis  with  advantage.  It  is,  however, 
to  be  borne  in  mind  that  large  doses  are  necessary  to  procure  results, 
and  that  these  preparations  contain  but  a  small  proportion  of  cod-liver 
oil. 


CHAPTER   XXXVII. 
SPECIFIC  TREATMENT. 

Strictly  speaking,  the  term  ''specific"  should  only  be  applied  to 
a  remedy  or  preparation  which  has  a  proved  selective  curative  efl^ect 
on  a  certain  disease.  From  this  viewpoint  we  can  state  unequivo- 
cally that  we  have  no  specific  remedy  for  tuberculosis  in  any  of  its  clin- 
ical forms.  We  have  no  substance,  drug,  or  preparation,  which  will 
cure  or  remove  or  ameliorate  the  symptoms  in  the  vast  majority  of 
phthisical  patients  to  the  same  degree  as  mercury  or  salvarsan  is  effica- 
cious in  syphilis,  quinine  in  malaria  or  thyroid  in  myxedema.  This 
is  a  fact  which  all  thoughtful  workers  in  the  tuberculosis  field  acknowl- 
edge ;  even  those  who  employ  tuberculin  extensively,  and  do  not  hesi- 
tate to  call  it  specific  treatment,  say  that  it  is  only  a  good  adjuvant 
to  other  therapeutic  methods  which  should  be  tried  in  selected  cases 
as  long  as  a  true  specific  is  not  available.  Moreover,  it  appears  that 
tuberculin  only  works  in  sanatoriums,  where  the  patients  are,  in 
addition  to  the  specific  treatment,  subjected  to  a  rigorous  hygienic 
and  dietetic  regime.  It  is  distinctly  stated  that  when  the  latter  is 
lacking,  tuberculin  is  of  no  avail. 

It  appears  that  the  only  justification  for  the  use  of  the  term  specific 
when  speaking  of  tuberculin  treatment  is  the  fact  that  this  word  has 
recently  received  a  wider  appKcation  and  is  now  also  used  to  designate 
remedies  which  are  especially  indicated  and  used  in  any  particular 
disease. 

The  writer  has  given  tuberculin  therapy  a  fair  trial  in  both  his 
hospital  and  private  practice  and  found  it  either  altogether  wanting 
in  therapeutic  effects  when  used  in  infinitesimally  small  doses,  as  is 
advised  by  most  of  its  contemporary  advocates,  or  decidedly  harmful 
when  given  in  substantial  doses.  This  opinion  is  shared  by  most  of 
those  engaged  in  the  treatment  of  tuberculosis,  excepting  such  as 
have  themselves  discovered  some  tuberculin,  or  who  are  in  charge 
of  sanatoriums  catering  to  well-to-do  private  patients.  In  the  public 
sanatoriums  in  this  country  very  little  of  tuberculin  is  used  for  thera- 
peutic purposes.  The  vast  majority  of  patients  in  these  institutions 
are  cared  for  by  the  old  methods.  It  cannot  be  said  that  it  is  the 
cost  which  precludes  the  use  of  tuberculin  in  public  institutions. 
Salvarsan  is  a  really  expensive  drug  but  is  used  in  all  hospitals. 

Our  reasons  for  discarding  tuberculin  from  the  therapeutic  arma- 
mentarium are  the  following: 

The  Variety  of  Tuberculins. — It  is  an  old  axiom  in  therapeutics 
that  the  larger  the  number  of  drugs  recommended  for  any  given  disease, 
the  less  the  chances  of  curing  it  with  any  of  those  mentioned  as  effica- 


THE   VARIETY  OF  TUBERCULINS  539 

cious.  Thus,  we  have  only  to  consult  the  index  of  any  standard  materia 
medica  and  count  the  number  of  remedies  recommended  for  typhoid 
fever,  pneumonia,  nephritis,  gastritis,  etc.,  and  to  compare  it  with 
the  number  mentioned  as  effective  in  myxedema,  malaria,  syphilis, 
valvular  heart  disease,  etc.,  to  be  convinced  that  the  axiom  holds 
good.  The  large  number  of  tuberculins  alone  should  give  us  a  strong 
hint  that  none  of  them  is  a  specific,  or  will  surely  cure.  I  counted  in 
one  recent  book  forty- six  varieties  of  tuberculins,  and  I  could  add 
almost  as  many  which  the  author  has  not  mentioned. 

"We  have  no  standard  tuberculin,"  says  Wilham  Charles  White,^ 
himself  an  advocate  of  tuberculin,  "and  furthermore  we  have  no 
manufacturer  who  prepares  the  same  strength  twice.  Consequently 
the  dose  of  one  tuberculin  is  no  more  the  dose  of  another  tuberculin 
than  the  dose  of  a  sherry  glass  is  the  dose  of  a  champagne  glass.  We 
have  no  method  of  testing  the  strength  of  a  given  tuberculin  unless 
it  is  the  biological  one,  and  this  is  tedious,  if  it  has  to  be  used  for 
every  patient  for  every  new  supply  of  tuberculin.  If,  however,  the 
tuberculin  standard  is  at  fault,  what  a  vastly  greater  differeilce  exists 
in  the  physicians  who  administer  it.  There  are  almost  as  many 
methods  of  dosage  and  administration  as  there  are  administrators. 
Each  physician  believes  his  method  the  best.  Some  have  no  method 
at  all."  It  appears  that  for  practical  purposes  we  have  no  methods 
to  weigh  or  measure  the  toxicity  of  tuberculins.  Two  preparations 
made  by  the  identical  method  may  differ  very  much  if  they  are 
derived  from  different  cultures,  especially  do  they  vary  with  the 
age  of  the  culture. 

All  authors  entitled  to  an  opinion  agree  that  the  action  of  all  tuber- 
culins is  the  same.  The  preparations  differ  only  as  regards  their 
strength,  toxicity,  capacity  for  absorption,  etc.  But  inasmuch  as 
the  active  element  or  substance  of  tuberculin  has  not  yet  been  isolated, 
nor  can  the  strength  of  a  given  preparation  be  measured,  it  appears 
that  the  differences  which  are  known  to  exist  between  the  various 
forms  of  tuberculin  cannot  be  definitely  ascertained.  Salvarsan, 
strychnin,  morphin,  digitalis,  or  tetanus,  and  diphtheria  antitoxin 
which  could  not  be  measured  would  hardly  be  used  by  medical  men. 

In  general  it  may  be  stated  that  there  are  three  varieties,  or  types 
of  tuberculin: 

1.  Old  tuberculin,  consisting  of  the  exotoxin — a  glycerin  extract 
containing  the  soluble  products  of  the  tubercle  bacilli  in  the  medium 
in  which  they  have  grown,  glycerin,  bouillon,  extractives,  etc.  Though 
it  should  be  mentioned  that  most  investigators  are  of  the  opinion  that 
there  is  no  tuberculous  exotoxin. 

2.  The  new  tuberculins,  made  up  of  the  insoluble  endoplasm  of  the 
bacilli  and  the  poisons  contained  within  them — endotoxins. 

3.  Those  which  consist  in  a  mixture  of  both  the  above  forms. 

'  Trans.  Fifth  Annual  Conference  Nat.  Assn.  Prev.  Consumption,  London,  1913,  p.  70. 


540  SPECIFIC   TREATMENT 

But  when  injected  into  the  tuberculous  human  or  animal  body  any 
tuberculin  produces  practically  the  same  effect.  On  this  nearly  all 
agree,  even  those  who  maintain  that  only  a  certain  variety  of  tuber- 
culin should  be  used  if  therapeutic  results  are  to  be  obtained. 

Action  of  Tuberculin. — As  was  already  stated  (see  p.  31),  tuber- 
culin is  harmless  when  injected  into  a  non-tuberculous  body,  and  pro- 
duces its  toxic  effects  only  in  those  who  have  suffered  a  tuberculous 
infection.  But  we  do  not  know  how  it  acts  under  these  circumstances. 
Wolff-Eisner's  tuberculolysin  hypothesis  is  about  the  most  plausible 
and  the  one  accepted  by  most  authors.  But  we  have  not  as  yet 
succeeded  in  isolating  a  specific  tuberculous  antibody,  nor  the  tuber- 
culolysin from  the  serum  of  infected  animals. 

At  first  sight  it  would  appear  that  tuberculin  is  specific,  considering 
that  it  acts  only  on  infected  organisms,  but  even  this  is  not  conclusive. 
It  seems  that  the  infected  organism  is  not  only  hypersensitive  to 
tuberculin,  but  to  all  foreign  proteins.  AYe  can  produce  elevation  of 
temperature,  malaise,  backache,  nausea,  etc.,  and  even  the  local 
reaction,  by  the  injection  of  any  foreign  protein  into  a  tuberculous 
person.  "Neither  the  local  nor  the  general  reaction  is  absolutely 
specific,"  says  Baldwin,^  himself  using  tuberculin  extensively;  "var- 
ious nucleoproteins,  yeast  nuclein,  bacterial  proteids  in  general,  and 
digestive  products,  such  as  albumoses,  are  capable  of  producing  sim- 
ilar effects.  Cinnamic  acid,  cantharidin,  pilocarpin,  and  other  alkaloids 
also  act  to  some  degree,  although  less  as  local  irritants  than  general 
leukocyte  stimulants."  In  my  experience  potassium  iodid,  and 
creosote,  when  given  in  large  doses,  may  produce  general  and  focal 
reactions  not  unlike  those  produced  by  tuberculin. 

All  efforts  at  producing  partial  or  complete  immunity  with  the 
administration  of  tuberculin  in  man  or  animals  have  utterly  failed. 
Even  Sahli,  who  urges  tuberculin  treatment,  says  that  "tuberculin 
treatment  has  not  the  character  of  a  true  immunization,  though  it 
produces  immunizatory  effects  in  the  organism." 

That  it  is  not  necessarily  the  reaction  which  is  effective  thera- 
peutically is  clear  when  we  consider  that  modern  tuberculin  treat- 
ment aims  at  eliminating  entirely  these  reactions  by  the  administra- 
tion of  infinitesimall}'  small  doses.  The  hope  that  the  focal  reactions, 
consisting  in  hyperemia  at  the  site  of  the  lesion  and  the  surrounding 
tissues,  may  promote  the  healing  of  the  lesion,  cannot  be  seriously 
entertained  by  clinicians.  Usually  when  the  focal  reaction  is  intense, 
it  cannot  be  controlled  and  the  congestion  often  produces  renewed 
activity  of  the  diseased  process.  Quiescent  foci,  calcareous  particles, 
are  "sleeping  dogs"  and  should  not  be  disturbed,  as  Sir  James  K. 
Fowler^  says.  The  establishment  of  tuberculin  tolerance,  which  some 
strive  at,  is  no  proof  of  healing;  in  fact  it  is  usually  short  lived.  ]More- 
over,  the  tuberculin  reaction  is  a  very  complex  process  and  varies 

'  Osier's  Modern  Medicine,  i,  .308. 

*  Trans.  Annual  Conference  Nat.  Assn.  Prev.  Consumption,  London,  1913,  v,  93. 


EVIDENCE  OF  LACK  OF  EFFECTS  OF   TUBERCULIN        541 

with  the  preparation  used,  the  individual  treated  and  also  with  the 
time  it  is  administered.  One  day  the  patient  is  tolerant,  the  other  he 
is  badly  affected  with  even  a  minimal  dose. 

There  is  no  harm  in  administering  most  drugs  in  teaspoonfuls, 
tablespoonfuls,  or  measuring  them  with  the  point  of  a  knife,  as  has  been 
done  for  centuries.  Patients  have  recovered  with  such  inexact  meas- 
ures, some  may  have  been  harmed,  but  lethal  doses  are  rarely  given 
in  this  manner.  But  we  cannot  give  a  potent  agent  like  tuberculin 
to  a  patient  who  needs  all  the  vital  energy  he  has,  and  more,  in  this 
manner,  any  more  than  we  can  give  with  impunity  strychnin,  mor- 
phin,  digitalis,  salvarsan,  etc.,  without  exact  dosage.  As  long  as 
we  cannot  measure  the  toxicity  of  tuberculin,  we  cannot  administer 
it  rationally  and  prevent  sudden,  and  at  times  harmful,  reactions 
which  may  appear  when  least  expected. 

Experimental  Evidence  of  the  Lack  of  Therapeutic  Effects  of  Tuber- 
culin.— Tuberculin  as  a  therapeutic  agent  is  based  on  results  obtained 
in  the  laboratory  through  animal  experimentation.  It  would  be 
reasonable  to  exact  that  it  should  be  efficacious  in  experimental  tuber- 
culosis in  animals.  But  it  is  a  fact  that  there  is  no  record  in  medical 
literature  that  any  investigator  has  succeeded  in  curing  or  benefiting 
a  tuberculous  animal  with  tuberculin  treatment.  In  Robert  Koch's 
writings  at  the  time  he  introduced  tuberculin  we  can  find  no  clear-cut 
statement  to  the  effect  that  he  cured  an  animal  with  this  agent. 
Klimmer,  Lydia  Rabinowitsch,^  and  others  have  recently  tried  small, 
very  small  doses,  corresponding  to  those  used  at  present  in  the  treat- 
ment of  human  phthisis,  but  the  tuberculous  guinea-pigs  and  rabbits 
failed  to  improve.  "No  curative  influence  has  been  exercised  by  the 
tuberculin.  The  control  animals  lived  sometimes  longer  than  the 
treated  animals.  On  the  use  of  large  doses  the  animals  readily  suc- 
cumbed." 

It  has  never  been  observed  that  the  administration  of  tuberculin  to 
tuberculous  animals  should  promote  healing  of  a  tuberculous  lesion, 
that  cicatrization  should  be  favored. 

What  has  been  observed,  however,  is  that  very  often  dormant 
tuberculous  processes  are  activated  after  the  administration  of  tuber- 
culin. Bacilli  which  gave  no  trouble  were  released,  "mobilized," 
producing  a  bacteremia,  as  was  already  mentioned  (see  p.  226). 

Serologically,  tuberculin  has  hardly  ever  shown  its  therapeutic 
value.  Like  other  antigens,  tuberculin  stimulates  the  production  of 
antibodies  when  inoculated  into  a  tuberculous  organism.  But  these 
antibodies  cannot  be  considered  true  antituberculins  because  they  do 
not  neutralize  tuberculin  in  vitro.  We  know  that  the  antibodies  pro- 
duced by  other  toxins,  as  those  of  tetanus  and  diphtheria,  neutralize 
the  toxins  of  these  infections  in  vitro,  while  the  tuberculous  antibodies 
do  nothing  of  the  kind.  We  can  consequently  see  no  theoretical  or 
practical  value  in  tuberculin  from  this  viewpoint. 

1  Trans.  Annual  Conference  Nat.  Assn.  Prev.  Consumption,  Loudon,  1913,  p.  44. 


542  SPECIFIC   TREATMENT 

Clinical  Evidence. — In  a  discussion  on  the  merits  of  tuberculin  treat- 
ment, Hector  W.  G.  Mackenzie^  said  that  "he  should  like  to  ask 
whether  anyone  has  been  able  to  obtain  a  cure  of  tuberculous  ulcer, 
arising  from  the  primary  inoculation  by  means  of  tuberculin  injec- 
tions.   He  fears  the  answer  must  be  in  the  negative." 

We  arrive  at  the  same  conclusion  when  we  consider  the  clinical 
evidence  presented  by  the  advocates  of  tuberculin  treatment  in  phthisis. 
All  effective  medication  has  its  indications,  contra-indications,  and 
limitations.  True  specific  treatment  is  not  free  from  these  limitations, 
as  is  true  of  quinin,  mercury,  salvarsan,  thyroids,  etc.  But  the  limi- 
tations in  the  range  of  usefulness  of  these  drugs  depend  mainly,  if 
not  entirely,  on  the  presence  or  absence  of  mixed  infection,  of  pre- 
existing diseases,  on  the  constitutional  peculiarities  of  the  patient 
and  complicating  diseases.  In  a  clear-cut  case  of  syphilis  in  the 
average  patient  salvarsan  or  mercury  will  produce  evident  curative 
effects;  malarial  fever  will  be  abated  by  quinin,  myxedema  is  relieved 
by  thyroids,  etc.  But  in  the  purest  forms  of  tuberculosis,  in  acute 
miliary  tuberculosis,  tuberculin  is  powerless,  which  fact  alone  should 
arouse  suspicion  as  to  its  specific  qualities. 

It  appears  to  be  a  general  rule  in  pathology,  as  has  been  pointed 
out  by  von  Hansemann,-  that  diseases  which  are  not  at  times  sponta- 
neously cured  cannot  be  cured  by  any  known  therapeutic  measure. 
Rabies  is  usually  mentioned  as  an  exception,  but  even  this  may  only 
be  prevented;  once  it  has  developed,  it  cannot  be  cured.  Specific 
therapeutics  aims  at  curing  diseases  which  are  not  kno\\Ti  to  be  cured 
spontaneously.  But  it  has  never  been  observed  that  a  patient  suffer- 
ing from  acute  miliary  tuberculosis  should  be  cured,  the  few  cases 
mentioned  by  Cornet  are  all  very  doubtful.  Acute  miliary  tubercu- 
losis is  the  purest  form  of  the  disease  without  mixed  infection;  the 
tubercle  bacilli,  though  disseminated  all  over  the  body,  are  found  in 
each  place  in  small  numbers  and  they  do  not  produce  avascular 
masses  from  which  medication  is  excluded.  It  should  be  the  crucial 
test  for  specific  treatment.  As  a  matter  of  fact,  however,  tuberculin 
is  altogether  powerless  in  acute  miliary  tuberculosis,  as  it  is  in  all 
progressive  cases  of  phthisis. 

Good  results  are  reported  by  those  who  have  used  it  in  glandular, 
osseous,  and  articular  tuberculosis  in  children.  But  we  have  already 
mentioned  that  these  have  a  strong  natural  tendency  to  heal  sponta- 
neously in  the  vast  majority  of  cases  (see  p.  391) .  Even  surgeons  advise 
and  practise  conservative  treatment. 

In  phthisis  the  ideal  cases  are  said  to  be  those  in  the  incipient  stage 
of  the  disease.  But  when  we  recall  that  a  really  incipient  case  is  one 
which  has  "  slight  or  no  constitutional  symptoms  including  particularly 
gastric  or  intestinal  disturbances  or  rapid  loss  of  weight;  slight  or  no 
elevation  of  temperature  or  acceleration  of  pulse  at  any  time  during 

'  Trans.  Annual  Conference  Nat.  Assn.  Prcv.  Consumption,  London,  1913,  p.  9. 
2Berl.  klin.  Wchnschr.,  1911,  xlvii,  1. 


DOSAGE  543 

the  twenty-four  hours/'  we  are  not  surprised  that  many  recover 
with  tubercuHn  treatment.  It  has  been  found  recently  that  in  Ger- 
many, France,  and  England  many  of  those  who  were  certified  as  tuber- 
culous and  eligible  for  sanatoriums,  were  fit  for  military  service. 
Instead  of  sending  them  to  institutions,  as  has  been  the  rule  during 
times  of  peace,  they  were  sent  to  the  trenches  and  in  the  vast  majority 
of  cases  they  stood  the  hardships  of  war  as  well  as  other  soldiers. 

The  reasons  for  this  anomaly  are  various.  Blomel  claims  that  80 
per  cent,  of  these  cases  were  wrongly  diagnosticated.  But  even  such 
as  showed  the  presence  of  tubercle  bacilli  in  the  sputum  were  found 
fit  for  military  service.  To  my  mind  there  are  many  cases  of  abortive 
tuberculosis  which  under  ordinary  circumstances  pass  as  chronic 
phthisis  and  any  form  of  treatment  gets  the  credit  for  the  cure. 
Tuberculin  evidently  gets  its  share  of  credit. 

Lack  of  Reliable  Statistics  of  the  Efficacy  of  Tuberculin. — To  prove 
its  therapeutic  efficacy,  a  specific  must  produce  results  in  a  larger 
proportion  of  cases  of  phthisis  than  is  observed  with  the  older  methods 
of  treatment.  This  has  not  been  shown.  In  fact  there  are  no  reliable 
statistics  of  large  series  of  cases  available.  In  their  book  on  tuber- 
culin treatment.  Riviere  and  Morland  state  that  they  decided  to 
give  no  statistics  of  results  of  tuberculin  treatment  because  they 
consider  figures  of  questionable  value.  Sahli  also  gives  no  statistics, 
while  the  figures  compiled  by  Brown  in  Klebs's  book  show  clearly  that 
there  is  no  difi^erence  in  results  between  the  group  treated  with 
as  compared  with  that  treated  without  tuberculin.  Statistics  of  ulti- 
mate results  are  not  available  at  all. 

Dosage. — It  would  be  pretty  bad  for  physicians,  and  for  patients, 
if  there  was  such  a  disagreement  as  to  the  dose  of  any  potent  remedy, 
especially  if  it  was  not  known  which  quantity  of  the  remedy  is  likely 
to  be  harmful.  The  initial  dose  ranges  between  1  mg.,  recommended 
by  Bandelier  and  Ropke  to  0.0000005  mg.,  recommended  by  Philippi. 
Between  these  two  extremes,  various  authors  recommend  intermediate 
quantities,  each  one  claiming  that  his  standard  is  best,  or,  what  is  of 
more  importance,  the  safest.  Still,  with  such  uncertainty  as  to  dosage, 
many  authors  make  tables  of  dosage,  and  iron-clad  rules  as  to  gradual 
increase  in  the  dose,  and  the  final  dose,  some  using  logarithmic  tables 
for  their  calculations,  as  if  they  were  dealing  with  an  exact  science. 

The  fact  is  that  there  is  no  mystery  about  the  technic  of  admini- 
stration of  tuberculin,  and  no  knowledge  of  higher  mathematics  is 
necessary  to  make  the  various  dilutions  properly.  Many  pharmaceuti- 
cal houses  sell  tuberculin  in  proper  dilutions  ready  for  use.  But  those 
who  want  to  make  their  own  dilutions  can  do  it  easily. 

All  that  is  necessary  is  six  or  ten  amber-colored  bottles  of  10  or  20 
c.c.  capacity  each.  They  are  to  be  clean  and  properly  sterilized.  A 
larger  bottle  containing  the  diluent  (sterilized,  or  distilled  water 
containing  0.8  per  cent,  of  sodium  chloride  and  0.5  per  cent,  of  carbolic 
acid)  should  be  at  hand.    Each  of  the  small,  colored  bottles  is  to  be 


544  SPECIFIC   TREATMENT 

filled  with  9  c.c.  of  the  diluent  and  marked  with  numbers,  I,  II,  III, 
IV,  V,  VI,  etc.,  respectively.  Now  take  1  c.c.  of  tuberculin  and  drop 
it  into  bottle  No.  I  and  shake  it  well.  It  now  contains  a  10  per  cent, 
solution  of  tuberculin,  so  that  a  syringeful,  with  a  capacity  of  1  c.c, 
contains  0.1  c.c.  of  tuberculin,  or  100  c.mm. 

When  we  take  1  c.c.  from  bottle  No.  I  and  drop  it  into  bottle  No. 
II,  we  get  a  solution  containing  1  per  cent,  of  tuberculin;  one  syringe- 
ful contains  10  c.mm.  of  tuberculin.  Repeating  the  process,  dropping 
1  c.c.  from  bottle  No.  II  into  bottle  No.  Ill,  the  latter  will  contain 
a  1  to  1000  dilution;  1  c.c.  equals  1  c.mm.  of  tuberculin;  bottle  No. 
IV,  a  1  to  10,000  dilution;  bottle  No.  V,  a  1  to  100,000  dilution; 
and  bottle  No.  VI,  a  1  to  1,000,000  dilution,  so  that  a  syringeful  will 
contain  a  dose  of  0.001  c.mm.  of  tuberculin.  These  dilution  may  be 
carried  further  and  the  dose,  which  should  always  be  small,  if  admin- 
istered at  all,  may  be  infinitesimally  so. 

If  given  for  its  psychic  effects,  which  is  in  fact  done  at  present  by 
most  who  use  this  agent,  it  is  advisable  to  have  ten  bottles  and  that 
the  first  injection  should  be  made  from  bottle  No.  X.  If  the  patient 
is  impressed  by  the  treatment,  he  will  "react"  at  least  with  0.3°  to 
0.5°  F.,  which  should  satisfy  any  one  who  is  looking  for  a  "mild 
reaction." 

Moreover,  there  is  no  difficulty  in  administering  properly  a  series 
of  ascending  doses  of  tuberculin,  and  no  higher  mathematics  is  neces- 
sary for  its  successful  accomplishment.  Taking  the  first  injection  as 
a  unit,  we  may  increase  the  next  injection  by  one-fourth  or  one-half. 
Thus,  supposing  we  have  used  at  first  the  dilution  in  bottle  No.  X 
containing  0.0000001  c.mm.  of  tuberculin  per  cubic  centimeter,  we  inject 
but  one-third  or  one-half  of  the  contents  of  the  syringe.  The  reaction 
is  not  likely  to  be  severe,  and  we  may  one  or  two  days  later  increase 
it  to  one-half  or  two-thirds  of  the  contents  of  the  syringe.  In  this 
manner  we  may  proceed  till  we  reach  bottle  No.  VI,  when  the  injec- 
tion of  a  syringeful  will  give  a  dose  of  0.001  cm.  It  is  not  advisable 
to  give  larger  doses  if  we  want  to  make  sure  that  the  patient  is  not 
harmed.  But  if  there  is  any  reaction  the  injections  should  be  stopped 
promptly. 

Utility  of  Tuberculin  Treatment. — It  cannot,  however,  be  denied 
that  some  good  results  have  been  obtained  with  tuberculin  treatment. 
Whether  they  could  not  be  obtained  with  other  methods  in  those 
cases  is  another  question.  Thus,  E.  Rist^  says,  "for  my  part,  I  have 
never  seen  a  patient  doing  well  under  tuberculin  without  remaining 
in  doubt  whether  he  would  not  have  done  as  well  without  tuberculin. 
Nor  have  I  met  with  cases  where  the  influence  of  tuberculin  was  so 
strikingly  favorable  that  I  could  feel  justified  in  letting  them  abandon 
the  classical  treatment  and  rely  on  tuberculin  alone."  Sir  James  K. 
Fowler  says:    "The  tuberculin  did  not  favorably  influence  the  course 

1  Paris  Medical,  1913,  iv,  241. 


PSYCHIC  EFFECTS  545 

of  the  disease  in  the  majority  of  cases;  in  some  cases  the  effects  were 
detrimental ;  and  even  in  stationary  and  improved  cases  it  was  difficult 
to  ascribe  any  distinct  improvement  to  the  injections  which  might  not 
have  been  equally  attained  under  the  treatment  ordinarily  employed 
in  the  Brompton  Hospital." 

In  the  extensive  Handbook  on  Tuberculosis,  A.  Schroder^  shows 
that  "It  has  been  established  that  in  institutions  for  the  treatment 
of  tuberculosis  in  which  only  general  treatment  is  applied,  the  lasting 
results  obtained  are  not  inferior  to  those  reported  from  institutions 
in  which,  in  addition  to  the  general  treatment,  so-called  specifics  are 
administered." 

Good  results  are  obtained  with  tuberculin  only  when  carefully  admin- 
istered in  sanatoriums,  with  cases  in  the  incipient  stage,  with  but 
slight  lesions,  most  of  which  are  spontaneously  curable.  Although, 
according  to  Brown,  at  the  Adirondack  Cottage  Sanatorium  no 
selection  is  exercised — the  patients  are  allowed  to  elect  tuberculin 
treatment.  In  private  practice,  as  well  as  in  most  tuberculosis 
clinics  in  cities  in  this  country,  attempts  with  tuberculin  have  failed, 
evidently  because  the  good  surroundings,  the  fresh  air,  the  proper 
food,  regulation  of  rest  and  exercise  were  of  more  importance  than 
the  tuberculin.  When  we  consider  further  that  even  the  most  ardent 
advocates  of  tuberculin  state  that  only  cases  without  fever,  pursuing 
a  slow  course,  showing  no  tendency  to  progress,  but  manifesting  a 
strong  tendency  to  fibrosis,  are  suitable  for  the  treatment,  it  is  clear 
that  tuberculin  is  a  remedy  for  those  forms  of  phthisis  which  are 
spontaneously  curable. 

Psychic  Effects. — We  have  seen  that  the  tuberculous  patient  is 
very  amenable  to  suggestion  (see  p.  236)  and  we  have  pointed  out 
that  in  a  certain  class  of  cases  tuberculin  produces  excellent  results 
for  this  reason.  On  this  point  a  large  number  of  physicians  agree,  and 
they  continue  to  administer  tuberculin  because  of  its  psychic  effects, 
although  they  may  as  well  administer  distilled  water  hypodermically 
and  obtain  the  same  results.  To  keep  nervous,  irritable,  fretful 
patients  for  months,  or  even  for  years,  is  a  difficult  matter;  often  it  is 
an  impossible  aft'air.  Something  must  be  done  in  addition  to  the 
rest,  fresh  air,  milk,  and  eggs,  of  which  he  believes  he  knows  as  much 
as  his  doctor.  Such  patients,  when  given  tuberculin,  told  to  watch 
out  for  reactions,  to  record  in  detail  the  symptoms  produced  by  each 
ascending  or  descending  dose  on  a  specially  prepared  blank,  are 
often  very  much  encouraged. 

This  view  of  the  psychic  action  of  tuberculin  is  entertained  by  most 
authoritative  physicians  who  use  this  agent  extensively.  Thus,  Law- 
rason  Brown,^  who  has  done  so  much  to  popularize  tuberculin  in 
this  country,  says  that  only  poor  results  can  be  expected  when  it  is 
given  "  in  cold  blood."    He  believes  "  its  value  can  be  greatly  enhanced 

'  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  der  Tuberkiilose,  1915,  ii,  3. 
2  Amer.  Jour.  Med.  Sei.,   1912,  cxliv,  524. 
35 


546  SPECIFIC   TREATMENT 

when  the  administrator  has  impHcit  faith  in  its  curative  properties 
and  imparts  that  faith  to  his  patients."  Another  significant  reason 
for  using  tubercuKn  treatment  according  to  Brown  "is  the  closer 
relationship  that  such  treatment  establishes  between  patient  and 
physician.  I  must  confess  that  I  find  it  difficult  to  bring  a  patient 
to  my  office  twice  a  week  for  months  and  discuss  symptoms  and 
fears,  one  of  which  gradually  grows  less  while  the  other  is  often  re- 
placed by  more  or  less  indifference,  borne  of  familiarity.  When,  how- 
ever, I  give  this  patient  tuberculin,  he  and  I  can  discuss  his  case  in 
detail  twice  a  week  and  I  am  able  to  discover  slight  but  important 
changes  in  his  condition,  to  check  imprudence,  and  to  change  needless 
timidity  into  confidence  in  his  ability  to  order  aright  his  life." 

But  similar  results  have  been  obtained  by  Mathieu  and  Dobrovici 
with  "  antiphymose"  as  was  already  detailed  (see  p.  443).  In  valvular 
heart  disease,  syphilis,  myxedema,  etc.,  this  does  not  work. 

I  believe  that  I  am  safe  in  saying  that  as  a  rule  tuberculin  treatment 
is  only  efficacious  in  intelligent  patients  who  are  under  the  impression 
that  they  have  mastered  the  theoretical  aspects  of  infection  and  im- 
munity and  of  specific  therapy  from  reading  popular  books  and  articles 
on  tuberculosis.  In  fact,  in  my  experience,  uneducated  patients  hardly 
ever  improve  under  tuberculin  treatment  because  they  cannot  under- 
stand the  benefit  of  fever,  malaise,  pain  in  the  limbs,  nausea,  debility, 
etc.  On  the  other  hand,  intelligent  patients  look  forward  to  the 
reaction  as  an  indication  that  the  tuberculin  is  "w^orking  on  their 
system"  and  they  often  improve,  provided  infinitesimally  small  doses 
have  been  given. 

There  is  no  agreement  among  authorities  as  to  what  constitutes  a 
"reaction"  during  tuberculin  treatment.  "All  physicians  are  agreed 
that  severe  reactions  are  harmful  to  the  patient  as  a  general  rule," 
say  Archer  W.  R.  Cochrane  and  Cuthbert  A.  Sprawson,^  "but  there 
is  still  considerable  difference  of  opinion  between  those  who  like  their 
course  to  progress  without  any  reactions  at  all,  and  those  who  prefer 
mild  reactions  as  a  routine.  Again,  opinion  varies  as  to  what  con- 
stitutes a  mild  reaction.  In  dealing  with  those  otherwise  running  a 
normal  temperature  the  limit  by  some  has  been  fixed  at  100.4°  F., 
and  reactions  thereto  are  disregarded;  that  is  to  say  these  physicians 
will  increase  the  next  dose  if  the  last  dose  has  not  given  a  reaction  over 
100.4°  F."  But  these  authors  consider  this  limit  too  high  or  danger- 
ous, and  are  satisfied  with  a  rise  to  99.2°  F.  and  call  it  a  reaction. 
In  other  words,  "the  timid,  or  no-reaction  school,"  treat  only 
afebrile  cases.  They  should  meet  with  immense  success,  because 
this  class  of  patients  recover  spontaneously  or  Avith  any  kind  of 
treatment. 

Dangers  of  Tuberculin  Treatment. — Since  the  first  use  of  tuberculin 
as  a  therapeutic  agent,  it  has  been  recognized  that  it  is  capable  of 

'  A  Guide  to  the  Use  of  Tuberculin,  Loudou,  1915,  p.  GO. 


DANGERS  OF   TUBERCULIN   TREATMENT  547 

doing  irreparable  damage  when  imprudently  administered.  Virchow 
found  that  it  produced  rapid  disintegration  of  the  tuberculous  tissues 
in  the  lungs,  caseous  pneumonia,  and  at  times  eruption  of  miliary 
tubercles.  More  recent  investigations  have  shown  that  it  often  mobil- 
izes the  bacilli  and  thus  may  favor  metastatic  auto-infection.  In  fact, 
if  phthisis  was  not  a  manifestation  of  immunity,  disastrous  results 
from  this  cause  would  be  very  frequent.  It  has  also  been  observed 
that  patients  taking  tuberculin  for  a  long  time  are  likely  to  develop 
n^ephritis.  To  be  sure,  with  infinitesimally  small  doses  the  likelihood 
of  such  complications  is  reduced  to  a  minimum,  but  the  most  expe- 
rienced administrator  is  often  surprised  by  unexpected  reactions.  I 
have  seen  such  results  repeatedly;  mostly  when  tuberculin  was  ad- 
ministered by  such  as  were  not  skilled  in  handling  this  potent  agent, 
but  also  at  times  in  patients  who  were  treated  by  very  skillful  physi- 
cians. 

Producing  hyperemia  of  the  affected  lung  area,  tuberculin  at  times 
is  effective  in  inducing  pulmonary  hemorrhage.  When  large  doses 
were  used  this  was  very  frequently  observed  and  reported  by  Frankel, 
Rumpf,  Strieker,  and  many  others.  "Since  small  doses  have  been 
used,"  says  J.  Sorgo,^  "with  a  view  of  avoiding  strong  reactions, 
hemoptysis  is  only  rarely  observed  after  the  administration  of  tuber- 
culin. At  times  small  hemoptyses  are  seen,  especially  streaky  sputum, 
but  copious  hemorrhages  are  rare.  For  this  reason  it  is  agreed  that  a 
tendency  to  hemoptysis  is  not  altogether  a  contra-indication  to  tuber- 
culin treatment,  provided  strong  reactions  are  avoided."  But,  as 
we  already  mentioned  this  is  not  possible  in  every  case.  All  who 
administer  tuberculin  for  therapeutic  purposes  stop  the  treatment 
as  soon  as  bleeding  makes  its  appearance. 

The  general  practitioner  should  not  use  tuberculin  at  all.  He  can 
obtain  the  same  results  by  the  judicious  use  of  drugs  without  incurring 
any  risk.  Even  psychotherapy  of  the  kind  applied  by  those  who 
administer  tuberculin  can  easily  be  practised  with  medication,  as 
was  shown  in  Chapter  XXVIII. 

1  Brauer,  Schroder,  and  Blumenfeld's  Handbuch  der  Tuberkulose,  1914,  ii,  255. 


CHAPTER  XXXVIII. 
SYMPTOMATIC  TREATMENT. 

Cough. — To  many  patients  the  cough  is  the  disease  and  they  are 
under  the  impression  that  all  they  need  for  a  speedy  recovery  is  to  be 
rid  of  this  annoying  and  painful  symptom.  In  its  treatment  some 
points  are  to  be  borne  in  mind :  In  most  cases  cough  is  decidedly  con- 
servative— a  purposeful  reflex  act;  it  removes  the  secretions  from  the 
respiratory  passages  which,  if  retained,  might  act  like  foreign  bodies 
or  produce  toxic  effects.  But,  on  the  other  hand,  cough  often  dis- 
turbs the  afi^ected  tissues  which  need  rest,  if  cicatrization  is  to  occur, 
or  it  may  be  responsible  for  hemoptysis,  pneumothorax,  etc.  Usually 
these  conflicting  principles  can  be  reconciled  by  appropriate  treatment. 

Cough  can  be  prevented  or  ameliorated  by  simple  measures  in  a 
large  proportion  of  cases.  Atmospheric  purity  contributes  consider- 
ably toward  a  reduction  in  its  frequency  and  severity.  Outdoor 
life  and  good  ventilation  of  the  room  inhabited  by  the  patient  meet 
this  indication.  Mouth-breathing  is  a  cause  of  excessive  coughing  in 
many  cases,  and  some  get  fits  of  coughing  when  suddenly  changing 
from  a  warm  into  a  cold  atmosphere,  or  the  reverse.  In  steam-heated 
rooms,  in  which  the  air  is  usually  dry,  cough  is  more  frequent  than  in 
rooms  in  which  the  air  contains  a  proper  amount  of  moisture. 

In  advanced  cases  with  secreting  cavities,  the  cough  may  be  influ- 
enced by  posture;  reclining  on  one  side  expectoration  is  facilitated, 
while  lying  on  the  other  side  brings  about  violent  fits  of  coughing. 
Patients  soon  find  out  which  position  gives  them  relief  and  recline 
accordingly.  These  patients  may  only  cough  during  the  morning 
hours  and  thus  empty  their  cavities  of  the  secretions  which  have 
accumulated  during  the  night,  while  during  the  day  there  is  but  little 
cough.    They  need  no  treatment  for  this  symptom. 

It  will  be  observed  that  some  phthisical  patients  who  sleep  well 
during  the  night  cough  more  during  the  day  than  those  who  cough 
more  or  less  during  the  night.  The  administration  of  large  doses  of 
opiates  during  the  evening  may  gain  relief  in  sleep,  but  also  result  in 
miserable  hours  during  the  following  day.  This  is  to  be  remembered 
when  administering  opiates  to  tuberculous  patients. 

Psychotherapy  of  Cough. — It  is  a  noteworthy  fact  that  the  cough  is 
greatly  influenced  by  the  psychic  state  of  the  patient.  Persons  with 
an  irritable  nervous  system,  the  hysterical,  emotional  and  neurasthenic, 
cough  n.ore  than  the  dull,  the  phlegmatic  and  apatiietic.  Home  cough 
while  in  the  house  and  are  relieved  as  soon  as  they  go  out  into  the 


COUGH  549 

open  air,  while  in  others  the  cough  increases  as  soon  as  the  wdndow  is 
opened,  or  when  they  go  out  into  the  open  air  on  a  cold  day.  This 
last  class  of  patients  is  very  difficult  to  manage. 

Other  psychic  influences  are  seen  in  patients  who  usually  cough 
excessively  but  cease  when  in  agreeable  company,  or  are  intensely 
interested  in  something,  etc.  I  have  practically  stopped  unproductive 
cough  in  many  patients  by  threatening  them  with  expulsion  from 
the  hospital  if  they  did  not  cease  annoying  their  fellow-sufi^erers  in 
the  ward.  Lonesomeness,  and  also  insomnia,  are  often  responsible 
for  excessive  cough  and  should  be  treated  according  to  indications. 
In  sanatoriums  the  influence  of  example  is  often  very  good:  The 
patient  sees  others  control  their  cough  and  attempts  to  do  likewise 
and  is  often  surprised  at  his  success. 

The  patients  can,  within  certain  limits,  control  their  cough,  as 
Galen  pointed  out  more  than  seventeen  centuries  ago,  and  Dett- 
weiler  has  shown  that  this  symptom  can  be  "disciplined."  Even 
when  the  cough  is  productive  of  considerable  quantities  of  sputum, 
the  patient  is  to  be  instructed  that  he  need  not  expel  it  all  at  once; 
that  if  he  succeeds  in  suppressing  it  for  some  time,  the  accumulated 
sputum  will  later  be  brought  out  with  little  effort.  During  the  morning 
hours  patients  often  make  strong  efforts  to  clear  their  chests.  But  if 
they  should  wait  till  after  breakfast  they  may  find  that  the  sputum 
comes  up  easily.  "Cough  induces  cough,"  says  Penzoldt,^  and  for 
this  reason  patients  are  to  be  warned  against  giving  in  to  the  first 
tickling  of  the  throat.  The  great  struggle  will  only  be  during  the 
first  two  or  three  days.  Meeting  with  success,  patients  become  con- 
vinced of  their  own  powers  to  suppress  or  control  this  symptom. 

But  patients  must  be  warned  in  this  connection  against  swallow- 
ing their  sputum — "spitting  into  their  own  stomachs."  Controlling 
does  not  mean  entirely  suppressing  expectoration  as  women  and  some 
men  are  apt  to  do.  The  dangers  of  the  habit  are  to  be  explained  in 
detail  to  the  patient. 

I  cannot  agree  with  those  who  prohibit  smoking  to  tuberculous 
patients  indiscriminately.  To  be  sure  those  who  are  not  accustomed 
to  tobacco  often  cough  when  near  a  person  who  smokes.  But  many 
habitual  smokers  are  greatly  relieved  by  a  cigar  or  cigarette.  Our 
advice  should  be  in  accordance  with  the  experience  of  the  individual 
patient. 

Many  home  remedies  are  very  often  efficacious  in  relieving  cough. 
Thus,  equal  parts  of  boiled  milk  and  honey  or  glycerin,  with  or  with- 
out a  flavoring  agent,  may  be  of  great  use  in  stopping  an  annoying 
cough.  An  excellent  remedy  is  the  application  of  a  small  mustard 
leaf,  or  blister  over  the  seat  of  the  lesion.  It  may  be  repeated  from 
time  to  time.  The  fact  that  it  works  by  psychic  suggestion  should  not 
deter  us  from  using  it,  so  long  as  the  patient  gets  relief. 

1  Handbuch  der  Therapie,  1910,  iii,  249. 


550  SYMPTOMATIC   TREATMENT 

Medicinal  Treatment. — After  all  the  cases  in  which  the  cough  may 
be  controlled,  or  made  bearable  by  simple  methods,  are  discounted, 
there  remain  a  large  number  who  must  be  given  sedatives  to  control 
this  symptom.  In  the  incipient  stage  these  remedies  are  only  rarely 
called  for,  and  then  only  for  a  short  time.  But  in  advanced  cases  the 
indications  for  sedatives  become  more  and  more  urgent.  As  Penzoldt 
sa^ys,  the  more  progressive  the  disease,  and  the  less  the  chances  of 
ultimate  recovery,  the  more  the  charity  of  morphine  is  to  be  dispensed 
to  the  unfortunate  sufferer. 

In  my  experience,  many  cases  in  the  incipient  and  moderately 
advanced  stages  of  the  disease  are  immensely  relieved  by  creosote  and 
its  derivatives.  The  method  of  administration  is  given  elsewhere. 
In  those  in  whom  internal  administration  does  not  relieve  the  cough, 
we  may  try  the  effects  of  inhalation  of  creosote,  menthol,  eucalyptol, 
tincture  of  benzoin,  etc.  The  following  is  as  good  as  any  that  has 
been  recommended: 

I^ — Creosoti, 

Acidi  carbolici, 

Spir.  chloroformi aa      giv  15.0 

M.     S. — Ten  to  twenty  drops  in  an  inhaler,  to  be  used  for  fifteen  minutes  at  a 
time. 

Failing  with  these  simple  remedies  we  must  resort  to  anodynes  in 
case  the  cough  is  frequent,  violent,  paroxysmal,  or  disturbs  the  patient's 
comfort  or  sleep.  Of  these,  cannabis  indicse  is  the  least  harmful  and 
should  be  given  the  first  trial.  The  extract  may  be  given  in  doses  of 
J  grain  in  pill  or  tablet  form  several  times  a  day.  In  spasmodic 
cough  it  may  be  combined  with  hyosciamus  or  gelsemium.  The  fol- 
lowing may  be  used  to  great  advantage: 

I^ — Extracti  cannabis  indicse •     .     gr.  vj  0.4 

Extracti  hyosciami .       .       .      gr.  xij  0.8  • 

M.  ft.  pU.  No.  xxiv. 

S. — One  pill  four  to  six  times  a  day. 

I^ — Extracti  cannabis  indicse  fl., 

Extracti  gelsemii  fl aa      Jij  S-0 

Syr.  acacise 5 J  30.0 

AquEe  menthse  piper ad      5iv  120.0 

M.     S. — -One  teaspoonful  four  times  a  day. 

In  many  cases  nothing  but  opiates  gives  relief.  But  in  incipient  cases 
opium  and  its  derivatives  are  to  be  avoided  because  it  may  have  to 
be  continued  for  long  periods  and,  in  hopeful  cases,  the  danger  of  habit 
formation  is  not  negligible.  In  addition  opium  deranges  the  digestive 
functions,  produces  anorexia  and  constipation,  slows  the  frequency 
and  the  amplitude  of  the  respiratory  movements,  and  favors  stag- 
nation of  the  secretions  in  the  respiratory  passages.  A  dose  of  Dover's 
powder  may  be  given  in  the  evening  now  and  then  with  a  view  of 
controlling  the  cough  during  the  night,  but  to  continue  the  a(hiiinis- 
tration  of  opium  in  any  form  for  any  length  of  time  is  dangerous. 


COUGH  551 

Of  the  many  opiates,  codein,  which  is  ten  to  twelve  times  less  toxic 
than  morphine,  is  to  be  preferred.  It  may  be  given  in  tablet  form  in 
doses  of  I  to  I  grain,  and  in  advanced  cases  even  in  much  larger 
doses  several  times  a  day;  or  it  may  be  added  to  any  other  medica- 
tion that  is  being  administered.  Thus  I  quite  often  add  it  to  creosote 
medication : 

I^ — Guaiacolis  carbonatis Siiss  10.0 

Strychninse  sulphatis        .       .       .       .      .       .      .      .  gr.  j  0.06 

Arsenici  trioxidi gr.  j  0.06 

Codeinse  phosphatis  .  .       .       .      . '     .       .  gr.  viij  0 . 5 

M.  ft  capsul.  No.  1. 

S. — One  capsule  three  times  a  day  after  meals. 

I^ — Codeinse  sulphatis gr.  iv  0.3 

Extracti  cannabis  indiciB             .       .       .       .       ,      .  gr.  vj  0.4 

Extracti  belladonnse .      .      .      .  gr.  iij  0.2 

Extracti  glycyrrhizae gr.  xij  0.8 

M.  ft.  pilullae  No.  xii. 

S. — One  pill  at  night. 

In  most  cases  in  which  sedatives  must  be  given  for  a  considerable 
time  the  dose  must  soon  be  increased  because  after  a  few  weeks  the 
effects  on  the  cough  are  diminished.  Instead  of  increasing  the  dose, 
we  may  do  better  by  changing  one  for  some  other  derivative  of  opium. 
Heroin  may  be  given  in  doses  of  ^4  to  |  grain  according  to  indi- 
cations. It  does  not  constipate  and  when  there  is  dyspnea  it  is  the 
best  palliative  remedy.  Dionin  is  another  of  these  preparations  and, 
when  insomnia  is  a  troublesome  feature,  it  is  even  better  than  the 
above.  Not  many  cases  of  habituation  to  dionin  have  been  reported, 
but  it  is  more  apt  to  cause  constipation  than  codein  or  heroin.  The 
two  last  mentioned  preparations  do  not  interfere  with  the  expectora- 
tion of  sputum;  some  even  maintain  that  they  assist  in  its  expulsion. 
Whenever  feasible  these  narcotics  are  not  to  be  given  after  midnight 
in  order  to  avoid  headache  and  debility  during  the  morning  hours. 

The  emetic  cough  is  a  very  difficult  symptom  to  control  in  some 
cases.  I  have  seen  some  in  whom  it  was  responsible  for  a  bad  turn  in 
an  otherwise  favorable  case.  Rarely,  no  food  can  be  retained.  Most 
can  be  relieved  by  avoiding  heavy  meals — taking  several  small  meals 
during  the  day.  The  patient  should  recline  in  bed  immediately  after 
meals  and  avoid  any  exertion  and  even  speaking.  But  at  times  we 
must  resort  to  medication.  Some  have  reported  good  results  from 
several  drops  of  chloroform  well  diluted,  or  from  bromoform.  I  have 
had  cases  in  which  only  cocain  administered  before  meals  was  effective 
in  retaining  nourishment  in  the  stomach.  The  following  prescription 
of  Albert  Robin  may  have  to  be  resorted  to: 

I^ — Cocain  hydrochloratis gr.  j  0.06 

Codein  sulphatis gr.  j  0 .  06 

Aquse  chloroformi Sij  60.0 

Aquae ad  giv  120.0 

M.     S. — Tablespoonful  after  meals. 


552  SYMPTOMATIC  TREATMENT 

Expectoration.— In  the  average  case  of  phthisis  expectoration  is  a 
salutary  phenomenon,  removing,  as  it  does,  foreign,  often  toxic, 
material  from  the  respiratory  passages.  At  times  it  becomes  excessive 
and  annoying,  but  it  should  never  be  suppressed.  In  some  cases  with 
extensive  excavations  the  amount  of  sputum  brought  up  may  be 
controlled  within  limits  by  posture.  We  advise  our  patients  to  recline 
in  certain  positions  which  favor  the  expulsion  of  sputum  and  thus 
empty  the  cavities  of  their  contents.  Relief  may  thus  be  obtained 
for  the  rest  of  the  day.  In  cases  in  which  the  sputum  is  fetid — rare 
in  phthisis — antiseptic  inhalations  may  be  tried.  Creosote,  iodin, 
menthol,  eucalyptol,  turpentine,  etc.,  may  be  inhaled  through  an 
inhaler  or  simply  dropped  in  hot  water  and  inhaled. 

Very  often  patients  complain  that  they  feel  heavy  on  the  chest  and 
that  if  they  could  only  bring  up  sputum  they  are  confident  that  they 
would  be  relieved.  Many  drugs  have  been  used  for  this  purpose, 
especially  the  so-called  expectorant  remedies.  It  seems  that  all  that 
is  usually  attained  is  a  disordered  stomach. 

It  appears  from  recent  pharmacological  investigation  that  there  are 
no  drugs  which,  when  given  in  small  doses,  will  induce  more  abun- 
dant secretion  into  the  respiratory  passages,  stimulate  the  cilia  of  the 
bronchial  mucous  membrane  to  bring  out  secretions,  or  render  tena- 
cious secretions  more  easily  movable  from  the  bronchial  walls  to 
which  they  adhere.  J.  L.  Miller^  found  that  ammonium  carbonate 
and  ammonium  chloride,  and  the  emetic  group  of  expectorants,  as 
apomorphin  and  ipecac,  when  given  in  suflficiently  large  doses  to 
animals,  increase  the  bronchial  secretion.  Ammonia  salts  per  os,  in 
moderate  doses  equivalent  to  2  mg.  in  an  adult  man,  do  not  increase 
bronchial  secretions  in  the  dog.  Apomorphin  and  emetin,  when  given 
to  dogs  in  doses  considerably  greater  than  the  ordinary  therapeutic 
dose  for  man,  do  not  excite  increased  bronchial  secretion. 

It  is  therefore  absurd  to  give  nauseating  potions  of  ammonium 
salts,  senega,  ipecac,  morphin,  etc.  All  we  may  succeed  in  doing  is 
to  disorder  the  stomach,  but  the  secretion,  in  the  respiratory  passages 
remains  unaffected. 

Fever. — Fever  is  an  indication  of  active,  often  progressive  phthisis, 
unless  due  to  some  complication.  Its  continued  presence  proves  con- 
clusively that  the  disease  is  spreading,  even  if  the  physical  signs  remain 
unaltered.  It  is  at  times  neglected  or  overlooked  because,  unlike  fever 
in  other  diseases,  the  patient  in  spite  of  a  temperature  of  over  100°  F. 
may  feel  quite  comfortable,  have  a  good  appetite,  and  even  gain  in 
weight.  But  the  entire  future  of  the  patient  may  depend  on  the 
treatment  of  the  fever;  neglecting  mild  febrile  attacks  means  an  invi- 
tation for  chronic  prolonged  fever  with  lessened  chances  of  reco\'ery. 

During  the  initial  stages  of  the  disease  fever  demands  rest  in  bed, 
not  so  much  as  a  cure  but  as  a  preventative  against  the  extension  of 

*  Amer.  Jour.  Med.  Sci.,  1914,  cxviii,  469. 


FEVER  553 

the  process  in  the  lung.  It  is  remarkable  that  in  many  cases  the  fever 
abates  within  a  few  days  or  a  week  only  through  an  improvement  in 
the  hygienic  conditions  and  the  diet  of  the  patient,  and  placing  him 
in  a  light  and  well- ventilated  room.  It  is  unfortunate  that  very  few 
patients  are  willing  to  submit  to  perfect  rest  at  this  stage,  claiming 
that  they  are  not  sick. 

There  are  many  advanced  cases  of  phthisis  with  quite  extensive 
lesions  in  which  there  is  a  daily  rise  in  the  temperature  of  1  to  1.5°  F., 
but  the  patients  feel  quite  well  and  are  even  able  to  pursue  their 
vocations.  They  need  no  active  treatment  because  they  have  become 
habituated  to  the  subfebrile  temperature  which  may  be  regarded  as 
their  normal  condition.  In  this  class  of  cases  it  is  only  necessary  to 
take  steps  to  reduce  the  temperature  when  the  patient  is  clearly 
suffering  as  a  result  of  it;  when  the  fever  produces  symptoms  such 
as  anorexia,  restlessness,  irritability,  insomnia,  etc.;  or  when  he  is 
losing  in  weight.  I  have  observed  many  cases  in  which  fever  was  due 
to  overfeeding,  and  a  reduction  in  the  quantity  of  food  has  promptly 
brought  the  temperature  down  to  normal. 

A  sudden  rise  in  the  temperature  in  the  course  of  chronic  phthisis 
may  be  due  either  to  an  extension  of  the  lesion,  a  new  pneumonic  pro- 
cess in  a  hitherto  unaffected  part  of  the  lung,  or  to  some  complication. 
The  former  demand  rest  in  bed  till  the  temperature  comes  down  to 
normal;  in  the  latter  the  indications  are  in  accordance  with  the 
pathological  conditions  which  present  themselves. 

Patients  are  apt  to  attribute  an  attack  of  fever  to  "indigestion," 
but  in  my  experience  acute  gastritis  is  a  rather  infrequent  cause  of 
pyrexia  in  phthisis,  though  a  dose  of  calomel  at  times  relieves  an 
evanescent  febrile  attack.  More  often  fever  lasting  several  days  is 
due  to  influenza  or  tonsillitis.  In  hospital  practice  there  is  at  times 
seen  an  actual  epidemic  of  these  diseases,  most  of  the  patients  in  the 
ward  are  attacked  during  a  period  of  a  couple  of  weeks.  The  treat- 
ment is  rest  in  bed  and  some  antipyretic,  like  antipyrin,  quinin,  aspirin, 
etc.  Complicating  pleurisy,  with  or  without  effusion,  may  be  the 
cause  of  a  rise  in  temperature.  In  some  women  premenstrual  or 
menstrual  fever  demands  rest  in  bed  periodically  for  a  few  days.  The 
instability  of  the  temperature  in  phthisis,  which  has  been  discussed  in 
a  previous  chapter,  is  responsible  for  many  febrile  attacks.  Any 
physical  or  mental  exertion,  worry,  grief,  and  anxiety  may  raise  the 
temperature  several  degrees.  Prophylactic  and  curative  action  is 
indicated  along  these  lines. 

The  fever  accompanying  active  phthisis  demands  active  treatment. 
The  main  aim  should  be  +o  remove  it,  or  to  prevent  its  occurrence.  If 
we  fail  in  this,  we  fail  in  our  efforts  at  relieving  the  patient.  It  may 
very  often  be  prevented  by  putting  a  patient  to  bed  at  the  very  first 
indication  of  a  tendency  to  hyperthermia  from  any  cause.  Indeed, 
the  neglect  of  mild  febrile  attacks  is  very  often  responsible  for  pro- 
longed and  even  fatal  fever. 


554  SYMPTOMATIC   TREATMENT 

In  high  continuous  fever  perfect  rest  is  indicated,  preferably  in  the 
open  air,  or  in  a  room  with  wide  open  windows,  as  has  already  been 
detailed  in  Chapter  XXXI.  The  patient  is  to  be  treated  as  though  he 
is  suffering  from  an  acute  disease,  like  typhoid  or  pneumonia.  It  is 
often  surprising  to  note  the  prompt  improvement  after  a  rest  in  bed 
for  a  few  days.  Patients  with  a  temperature  at  a  high  level  for  several 
months  are  often  difficult  to  manage.  When  accompanied,  as  it 
usually  is,  by  progressive  loss  of  appetite,  weight,  and  strength,  they 
become  discouraged  and  rebel  against  the  prolonged  and  strict  con- 
finement. In  such  cases,  provided  the  temperature  is  below  101°  F., 
the  experiment  may  be  made  of  permitting  them  to  leave  the  bed  and  get 
out  in  the  open,  resting  on  a  reclining  chair  for  a  few  hours  during  the 
day.  The  best  hours  are  before  or  around  midday,  when  the  tempera- 
ture is  usually  at  its  lowest;  but  any  other  time  may  be  chosen  under 
the  guidance  of  the  thermometer.  In  hectic  cases  the  temperature  is 
usually  at  its  lowest  in  the  morning  and  the  patient  may  be  allowed 
to  leave  his  bed  at  that  time.  I  have  seen  many  patients,  who  did 
badly  for  weeks,  improve  when  allowed  to  remain  in  the  upright  or 
semiupright  position  for  several  hours  a  day.  But  care  and  circum- 
spection are  to  be  exercised  while  applying  this  treatment. 

Some  patients  may  be  sent  to  the  country  and  the  change  is  at  times 
effective  in  reducing  the  temperature  when  everything  else  has  failed. 
But  this  is  not  available  to  patients  who  have  not  the  means  to  leave 
accompanied  by  an  attendant.  Many  authorities  state  that  a  moun- 
tainous climate  is  to  be  preferred  for  this  purpose,  but  in  my  expe- 
rience any  change  may  do  just  as  well. 

It  is  deplorable  that  public  sanatoriums  do  not  admit  febrile  cases. 
Great  service  could  be  rendered  by  removing  the  patient  for  several 
weeks,  during  the  period  of  fever,  to  better  surroundings,  giving  him 
an  opportunity  to  rest  without  interference  by  well-meaning,  but  often 
ill-guided,  relatives  and  friends.  I  have  often  felt  that  cases  under 
my  care  could  be  saved  if  sanatoriums  were  managed  along  hospital 
lines,  admitting  patients  during  acute  exacerbations  in  the  places 
which  are  now  filled  with  patients  whose  condition  is  such  that  they 
would  do  well  in  any  healthy  surroundings  which  can  be  obtained 
in  the  average  home. 

Hydrotherapeutic  measures  have  not  been  found  satisfactory  in  the 
treatment  of  fever  in  phthisis.  The  use  of  ice,  or  of  cold  sponging,  or 
bathing,  although  possibly  of  temporary  benefit,  is  contra-indicated 
in  most  cases  because  they  are  apt  to  depress  the  patient.  The  most 
that  can  be  done  is  to  give  a  warm  or  tepid  bath  once  or  twice  a  week 
for  the  purpose  of  cleansing  the  body,  but  care  is  to  be  taken  not  to 
subject  him  to  overexertion  while  going  and  coming  from  the  tub. 
The  fact  that  hydrotherapeutic  methods  have  been  given  up  in  nearly 
all  sanatoriums  is  suflficient  proof  that  they  have  not  been  beneficial; 
in  fact  that  they  were  harmful. 

Artificial  pneumothorax  is  an  excellent  radical  measure  against 


FEVER  555 

tuberculous  fever  in  appropriate  cases.  This  will  be  discussed  in 
Chapter  XXXIX. 

Antipyretic  Medication. — Antipyretic  drugs  should  only  exceptionally 
be  used  in  phthisis.  In  the  first  place  tuberculous  patients  do  not,  as 
a  rule,  suffer  from  the  pyrexia  to  the  same  extent  as  patients  with 
typhoid  fever,  pneumonia,  etc.,  and  a  reduction  in  the  temperature 
does  not  necessarily  give  the  relief  which  the  patient  anticipates.  It 
is  not  the  fever,  excepting  hyperpyrexia,  which  is  dangerous,  but  the 
activity  of  the  tuberculous  process,  and  as  long  as  only  the  former  is 
influenced,  the  patient  is  not  materially  benefited. 

The  action  of  antipyretic  drugs  is  ephemeral  and  deceptive,  often 
accompanied  by  profuse  perspiration  which  is  enervating;  and  by 
digestive  disturbances.  Large  and  frequently  repeated  doses  are 
necessary  for  weeks  in  the  usual  cases  and  their  action  on  the  heart, 
which  is  not  salutary,  often  leads  to  collapse. 

But  when  the  fever  is  accompanied  by  headache,  backache,  and 
debility,  one  of  the  coal-tar  antipyretics  may  give  comfort  with  or 
without  reducing  the  temperature.  Acetanilid  is  to  be  avoided  for 
well-known  reasons.  Phenacetin  acts  too  quickly  and  produces  profuse 
sweating.  Antipyrin,  or  better,  pyramidon  may  be  used  in  5-  to  10- 
grain  doses,  combined  with  caffeine.  Patients  may  stand  the  fever 
without  complaining  much,  but  in  septic  cases  they  abhor  the  chills 
which  are  apt  to  occur  before  the  onset  of  the  pyrexia.  The  best 
treatment  is  to  place  the  patient  in  bed  a  few  hours  before  the  appear- 
ance of  the  chill,  cover  him  well,  and  give  him  a  drink  of  hot  lemonade, 
tea,  or  whisky  and,  in  severe  cases,  a  dose  of  pyramidon.  The  chill 
may  in  this  manner  not  be  prevented  completely,  but  it  is  rendered 
bearable.  On  the  whole,  antipyretic  medication  is  to  be  administered 
an  hour  or  so  before  the  highest  temperature  is  expected,  varying 
with  each  case.  Quinin  should  be  given,  if  at  all,  five  to  six  hours  before 
the  maximum  temperature  is  expected,  while  pyramidon,  antipyrin, 
aspirin,  etc.,  require  but  two  to  three  hours.  When  the  fever  has 
declined  medication  should  not  be  continued,  otherwise  collapse  may 
occur. 

The  salicylates  'are  often  very  good  in  these  cases,  especially  in  the 
chronic  hectic  fever  of  consumption.  The  old  prescription  of  sodium 
salicylate  and  arsenous  acid  (sod.  salicyl.,  10;  acid,  arsenicosi,  0.01; 
ft.  pil.  no.  100;  S.,  five  to  ten  pifls  three  times  a  day  after  meals)  is 
very  good.  But  I  have  found  that  7  to  10  grains  of  aspirin  and  ^z'o 
gr.  of  arsenic  in  capsule  three  times  a  day  is  better.  It  is  less  likely 
to  disturb  digestion.  But  in  patients  showing  a  tendency  to  hemop- 
tysis the  salicylates  are  to  be  avoided.  Pyramidon  is  best  for  this 
class  of  patients. 

An  excellent  remedy  for  fever  in  tuberculosis  is  guaiacol  painted  with 
a  camel-hair  brush  on  the  skin  in  7-  to  15-drop  doses  and  covered 
air  tight.  The  temperature  drops  sometimes  within  one  hour.  It  is 
best  to  rub  into  the  skin  of  the  thorax  a  teaspoonful  of  a  10  per  cent. 


556  SYMPTOMATIC   TREATMENT 

guaiacol-vaselin  ointment  two  or  three  times  a  day.  It  must  be 
mentioned  that  collapse  has  been  observed  in  some  cases  after  the 
application  of  guaiacol. 

Nightsweats. — No  other  symptom  of  chronic  phthisis  is  more  dis- 
couraging and  enervating  than  nightsweats  and  their  relief  is  of 
immense  importance.  It  seems  that  in  the  vast  majority  of  cases  they 
can  be  prevented  without  the  use  of  medication  and  many  physicians 
state  that  with  careful  prophylaxis  they  have  not  used  any  drugs  for 
this  symptom  for  years. 

Open-air  treatment  is  the  best  preventative  of  nightsweats.  Sleep- 
ing in  a  cold  room  with  sufficient  but  not  excessive  covering  must 
be  enjoined.  It  is  also  good  to  give  the  patient  before  retiring  a  glass 
of  cold  milk  wuth  three  or  four  teaspoonfuls  of  cognac  to  prevent  the 
rapid  sinking  of  the  pulse  rate.  In  some  cases  a  roll  with  butter  may 
serve  the  same  purpose.  Some  cases  may  be  relieved  by  noting  the 
time  of  the  beginning  of  the  sweating,  and  waking  the  patient  a  few 
minutes  before  and  giving  him  an  ounce  of  whisky.  For  private  patients 
an  alarm  clock  may  be  used  for  the  purpose.  This  method,  recom- 
mended by  William  Porter/  should  be  tried  in  all  obstinate 
cases. 

In  cases  in  which  these  simple  measures  do  not  succeed,  the  sulphate 
of  atropin  in  doses  of  y^^j  grain,  given  in  tablet  form  about  seven 
o'clock  in  the  evening,  may  give  complete  relief.  Agaricin  is  also  good 
in  doses  of  2V  grain,  but  it  acts  more  slowly  and  must  be  adminis- 
tered about  six  hours  before  the  sweating  is  expected.  It  often  produces 
gastro-intestinal  disturbances,  especially  diarrhea,  and  should  be  com- 
bined with  an  opiate — Dover's  powder  in  3-  to  5-grain  doses.  It  is  to 
be  remembered  that  no  remedy  retains  its  power  over  this  symptom 
for  a  long  time,  and  after  one  ceases  to  act,  we  may  try  another. 

Friction  of  the  skin  with  tepid  water,  or  vinegar  or  alcohol  and 
water,  or  a  3  per  cent,  lysol  solution,  may  give  relief. 

Hemoptysis. — The  prophylaxis  of  hemoptysis  cannot  be  considered 
an  easy  matter  despite  the  fact  that  we  speak  so  much  about  the  pre- 
disposing and  exciting  factors  of  pulmonary  hemorrhage.  Patients 
with  really  initial  hemoptyses  always  consult  us  after  the  accident 
has  occurred;  and  while  many  of  the  hemorrhages  occurring  during 
the  course  of  phthisis  have  some  exciting  cause — overexertion,  excite- 
ment, acute  exacerbations  of  the  process,  etc. — behind  them,  there 
are  just  as  many  in  which  the  patient  had  been  at  perfect  rest 
physically  and  psychically.  In  fact,  many  of  the  copious  and  fatal 
hemorrhages  occur  during  the  night,  when  the  patients  were  asleep. 
However,  all  patients  with  pulmonary  tuberculosis  are  to  be  told  in 
advance  that  there  is  less  danger  in  blood-spitting  than  is  gen- 
erally believed.  We  would  thus  avoid  the  psychic  depression  which 
is  so  often  an  accompaniment  of  hemoptysis.     Women  may  be  told 

1  International  Clinics,  Sixteenth  Series,  190G,  iv,  77. 


HEMOPTYSIS  557 

that  in  the  average  ease  of  hemoptysis  there  is  no  more  danger  than 
in  the  loss  of  blood  during  the  menstrual  period. 

Not  all  cases  of  hemoptysis  require  the  same  treatment;  individ- 
ualization is  required  here,  just  as  in  most  other  pathological  condi- 
tions. The  vast  majority  of  hemorrhages  are  insignificant,  and  if  we 
only  place  the  patient  at  rest  in  bed,  and  quiet  him  by  an  assurance 
that  there  is  little  danger,  the  bleeding  will  cease  sooner  or  later  and 
the  underlying  process  in  the  lung  pursues  its  course  uninfluenced  by 
the  accident.  This  is  true  of  streaky  sputum,  which  often  terrorizes 
a  patient  to  the  same  extent  as  a  copious  hemorrhage.  But  when  the 
blood  brought  up  is  bright  red,  even  if  only  a  few  mouthfuls,  the  mat- 
ter is  to  be  taken  more  seriously  because  these  small  hemorrhages  are 
at  times  the  precursors  of  repeated  and  copious,  though  rarely  uncon- 
trollable, hemorrhages.  Immediate  and  absolute  rest  is  to  be  enjoined 
and  strong  measures  taken  to  stop  the  bleeding. 

The  patient  is  put  to  bed,  but  not  in  the  traditional  prone  position. 
The  blood  and  sputum  must  be  evacuated  from  the  respiratory  pas- 
sages with  ease  and  this  can  only  be  done  when  the  patient  is  in  the 
semisitting  position.  In  this  manner  nourishment  and  medication 
can  be  administered  without  unduly  disturbing  the  patient,  expectora- 
tion is  facilitated  and,  in  copious  hemorrhages,  atelectasis  of  the  pos- 
terior parts  of  the  lung  is  prevented.  With  a  view  of  keeping  a  patient 
at  perfect  rest  an  ice-bag  is  to  be  applied  to  the  chest.  We  know  of 
no  other  value  to  this  time-honored  procedure.  The  patient  is  to  be 
warned  against  any  motion  of  the  body  and  even  speaking  is  prohibited. 
Only  after  several  days  without  any  blood  in  the  sputum  may  the 
patient  be  permitted  to  assume  the  upright  position. 

The  therapeutic  indications  to  be  met  in  addition  to  rest  are:  Pre- 
vention of  excessive  cough  and  expectoration;  increasing  the  coagula- 
bility of  the  blood;   and  immobilization  of  the  bleeding  lung. 

Morphin.^ — To  allay  excitement,  procure  rest,  and  thus  prevent  exces- 
sive cough,  there  is  no  better  remedy  than  a  hypodermic  injection  of 
morphin.  We  must  bear  in  mind  that  we  are  in  the  presence  of  a 
conflicting  situation.  On  the  one  hand,  we  must  see  to  it  that  the 
effused  blood  in  the  bronchial  tree  should  be  removed;  on  the  other 
hand,  the  strong  expiratory  efforts  necessary  to  accomplish  the 
expulsion  of  the  blood  and  clots  are  accompanied  by  an  increase  in 
the  pressure  in  the  pulmonary  circulation  and,  with  their  removal,  the 
thrombi  which  plug  the  bleeding  vessel  are  dislodged  and  thus  renewed 
bleeding  is  likely  to  occur.  Morphin  meets  but  one  of  these  indica- 
tions: It  depresses  the  cough  centre,  diminishes  the  frequency  and 
amplitude  of  the  respiratory  movements  and  quiets  the  mental  state 
of  the  patient.  Some  have  even  found  that  morphin  increases  the 
coagulability  of  the  blood.  But  after  all  it  has  its  dangers.  When 
given  to  excess,  as  is  often  done,  it  depresses  the  respiratory  centre, 
paralyzes  the  sensibility  of  the  bronchial  mucous  membrane  and  thus 
interferes  with  the  expulsion  of  the   blood   and  clots.     Aspiration 


558  SYMPTOMATIC   TREATMENT 

pneumonia  may  thus  result  in  cases  in  which  it  is  more  successful  as 
a  hemostatic  than  is  desirable. 

For  this  reason  morphin  is  to  be  used  with  great  care  and  circum- 
spection. Finding  the  patient  excited  and  in  agony,  we  inject  h^'po- 
dermically  j  grain  of  morphin  for  its  general  and  local  effects.  If  the 
bleeding  does  not  stop  within  an  hour  the  morphin  should  not  be 
repeated,  but  other  means  are  to  be  taken  to  control  the  hemorrhage. 

Emetin. — In  former  time  emetics  were  given  in  hemoptysis  and  excel- 
lent results  were  reported  because  with  the  vomiting  the  effused  blood 
in  the  bronchi  was  also  expelled  preventing  asphyxiation  and  also 
because  the  nauseous  feeling  reduced  the  blood-pressure  perceptibly. 
Following  Trousseau's  suggestion,  large  doses  of  ipecac  were  given  for 
this  purpose.  But  we  now  have  in  emetin  an  excellent  substitute  for 
the  nauseous  ipecac.  It  acts  as  a  hemostatic  when  many  other  agents 
have  failed.  I  have  used  it  in  f -grain  doses,  repeated  three  to  five 
times  a  day,  with  satisfaction.  The  simplest  way  of  administration  in 
these  cases  is  hypodermically.  Either  the  tablets  or  the  ampoules, 
which  many  pharmaceutical  houses  prepare,  may  be  used  for  the  purpose. 

Salt. — Another  ancient  remedy  for  copious  hemorrhage  is  the  ad- 
ministration of  table  salt.  Formerly  it  was  thought  that  because 
it  acts  as  an  emetic,  and  thus  depresses  the  blood-pressure,  it  is  of  use 
in  hemoptysis.  But  we  now  know  that  its  modus  operandi  is  different. 
Von  den  Yelden^  has  proved  that  in  man,  swallowing  5  to  15  grams  of 
table  salt  increases  the  coagulability  of  the  blood  within  five  minutes. 
Within  one  hour  the  coagulability  returns  to  its  former  intensity. 
Sodium  bromide  has  nearly  the  same  effect.  For  this  reason  the 
administration  of  5  to  10  grams  of  table  salt  or  3  grams  of  sodium 
bromide  tlu-ee  to  foiu  times  a  day  may  prove  of  immense  value  in 
hemoptysis;    In  very  nervous  patients  the  bromide  is  to  be  preferred. 

More  recently  salt  has  been  administered  intravenously  in  isotonic 
solution  as  recommended  by  Hans  Miiller.-  Ten  to  50  c.c.  of  a  10  per 
cent,  solution  of  sodium  chlorid,  sterilized  and  heated  to  the  body 
temperature,  is  injected  into  the  median  basilic  vein,  great  care  being 
taken  not  to  drop  any  of  the  solution  into  the  subcutaneous  tissue 
which  is  likely  to  cause  intense  pain.  I  have  tried  this  treatment  and 
found  it  satisfactory  in  many  cases. 

Ijing  the  Extremities. — The  coagulability  of  the  blood  is  also  in- 
creased by  tying  up  the  blood  in  the  extremities.  A  constricting  band 
or  a  tourniquet  is  tied  around  the  arm  and  the  hip;  two  or  three  of  the 
extremities  are  tied  up  at  a  time.  In  order  to  avoid  injury  to  the 
nerves  a  roller  bandage  or  any  other  soft  pad  should  be  placed  under 
the  tourniquet  over  the  path  of  the  larger  vessels.  The  bandage  should 
not  remain  in  place  for  more  than  two  hours,  otherwise  muscular 
paralysis  or  necrosis  of  the  skin  may  result.  As  a  ride,  one-half  hour 
is  sufficient.    The  bandage  is  to  be  removed  slowly  for  obvious  reasons. 

1  Ztschr.  f.  exper.  Pathol,  u.  Therupie,  1910,  vii,  290. 
^  Beitr.  z.  Klinik  d.  Tuberkulose,  1913,  xxviii,  1. 


HEMOPTYSIS  559 

Artificial  Pneumothorax. — In  cases  in  which  the  above  measures  are 
of  no  avail,  the  induction  of  an  artificial  pneumothorax  may  be  con- 
sidered, provided  it  can  be  ascertained  in  which  side  of  the  chest  the 
bleeding  is  going  on.  This  point  is  discussed  elsewhere  in  this  book. 
But  it  should  be  stated  that  in  very  acute  cases  in  which  the  exsan- 
guination  is  sharp  and  brisk,  there  is  usually  nothing  to  lose  and,  even 
when  we  are  not  sure,  we  are  justified  in  inducing  a  pneumothorax  in 
the  pleura  of  the  lung  which  is  most  likely  the  source  of  the  bleeding 
as  shown  by  clinical  indications. 

Medicinal  Treatment. — It  will  be  noted  that  with  exception  of  emetin 
we  have  left  the  drugs  which  have  been  used  for  the  purpose  of  allay- 
ing pulmonary  hemorrhage  to  the  end.  The  reason  is  that  we  do  not 
know  of  any  drug  which  will  stop  hemorrhage  in  the  lung.  It  seems  to 
me  that  the  reputation  of  some  drugs  as  pulmonary  hemostatics  has 
been  acquired  on  the  basis  of  the  fact  that  the  vast  majority  of  hemor- 
rhages stop  spontaneously;  anything  will  do  and  receive  the  credit. 
This  appears  to  be  the  consensus  of  opinion  of  phthisiotherapeutists 
at  present,  although  no  less  an  authority  than  Albert  Robinf  says 
that  he  feels  constrained  to  protest  vigorously  against  the  allegation 
that  medicinal  agents  are  impotent,  and  are  only  given  credit  for  their 
psychic  effects.  To  be  sure,  he  says,  there  are  many  cases  of  hemop- 
tysis which  stop  spontaneously  with  or  without  treatment;  there 
are  others  which  cannot  be  controlled  by  any  treatment.  But  between 
these  two  extreme  types  there  are  many  cases  in  which  medicinal 
treatment  has  a  decidedly  beneficial  influence.  Among  these  drugs 
Robin  mentions  ergot,  calcium  .chlorid,  gelatin,  trinitrin,  adrenalin, 
ipecac,  digitalis,  etc. 

The  Nitrites. — The  nitrites  have  been  found  efficient  in  checking 
the  bleeding  from  the  lung.  They  are  known  to  lower  the  blood- 
pressure  and  this  may  be  the  cause  of  their  efficacy.  Macht^  found 
experimentally  that  the  nitrites  cause  a  constriction  of  the  pulmonary 
vessels  and  at  the  same  time  they  are  efficient  peripheral  and  splanchnic 
vasodilators.  As  usually  given  in  2  or  3  drops,  amyl  nitrite  is  often 
inefficient.  I  found  that  J.  E.  Squire's^  suggestion  to  give  10  to  15 
drops,  dropped  on  a  handkerchief  which  is  placed  before  the  patient's 
mouth  and  nose,  is  best.  Immediately  the  face  becomes  red  and  con- 
gested and  the  hemorrhage  stops.  It  may  be  repeated  several  times 
during  the  day.  In  more  copious  hemorrhages,  where  the  nose  gets 
blocked  up  with  blood  and  clots,  it  may  be  necessary  to  put  from  30 
to  50  minims  on  a  piece  of  lint  and  hold  it  over  the  patient's  mouth. 
It  may  have  to  be  repeated  and  the  only  complaint  heard  from  the 
patient  is  that  it  produces  a  feeling  of  nausea.  C.  Fochi*  says  that 
when  administered  as  soon  as  the  first  traces  of  blood-spitting  are 

1  Therapeutique  uselle  de  la  tuberculose,  Paris,  1912,  p.  294. 

-Jour.  Amer.  Med.  Assn.,  1914,  Ixii,  524. 

3  Clinical  Journal,  1909,  xxxiv,  155. 

^  Gazzetta  degli  Ospedali,  1908,  xxix,  114, 


560  SYMPTOMATIC   TREATMENT 

seen,  copious  hemorrhages  may  be  prevented.  But  this  is  open  to 
question.  Fatal  hemoptysis  only  rarely  begins  with  streaky  sputum. 
It  is  copious  from  the  start,  as  a  rule. 

In  slow  bleeding,  nitroglycerin,  given  in  small  and  frequently 
repeated  doses,  as  recommended  by  Flick,  is  often  of  service.  When 
administered  in  2-  to  4-drop  doses  of  the  1  per  cent,  alcoholic  solution 
it  produces  the  same  effect  as  amyl  nitrite,  but  slower  and  more  lasting 
effects  are  observed.  Tablets  are  not  to  be  trusted  because  they  are 
often  inert,  as  has  been  shown  by  George  B.  Wallace  and  A.  I.  Ringer.^ 
The  1  per  cent,  solution,  as  represented  by  the  pharmacopoeal  spirits,  is 
the  best  form  in  which  glonoin  should  be  administered.  The  following 
formula  may  be  prescribed: 

I^ — Spirit,  glonoini 3j  4.0 

Aquae  aurantii  flor Sj  30.0 

AquEe  destil ad  giv  120.09 

M.     S. — One  teaspoonful  three  or  four  times  a  day. 

Adrenalin. — During  recent  years  adrenalin  has  been  used  quite 
extensively  for  hemoptysis.  It  has  been  stated  that  it  works  well  in 
cases  where  it  is  likely  that  the  hemorrhage  is  due  to  the  erosion  of 
a  medium-sized  vessel,  and  that  in  acute  inflammatory  conditions 
of  the  lung  it  is  contra-indicated.  It  increases  the  heart  action  and 
contracts  the  bloodvessels,  especially  of  the  intestines,  kidneys,  and 
spleen,  and  thus  increases  the  blood-pressure.  But  Gerhardt  says  that 
the  bloodvessels  of  the  lung  are  but  slightly  contracted,  while  Frey 
found  that  in  a  bleeding  lung  in  a  rabbit  the  vessels  dilated  and  the 
flow  of  blood  was  increased  after  the  administration  of  adrenalin,  and 
Macht^  found  experimentally  that  it  causes  a  powerful  constriction  of 
the  pulmonary  artery.  Moreover,  according  to  von  den  Velden,  the 
coagulability  of  the  blood  is  increased  50  per  cent,  after  the  sub- 
cutaneous administration  of  the  remedy.  Clinical  experience  with 
this  drug  has  not  convinced  the  writer  of  its  efficacy  in  hemoptysis 
and  it  has  therefore  been  discarded. 

Ergot. — Ergot  has  been  given  in  large  doses  (a  teaspoonful  of  the 
tincture  every  three  or  four  hours;  ergotin  hypodermically).  But  it 
has  been  conclusively  shown  that  it  increases  the  pressure  in  the 
lesser  circulation,  just  what  we  want  to  avoid.  In  the  writer's  experi- 
ence it  has  never  been  of  any  value,  often  decidedly  harmful.  The 
same  may  be  said  about  digitalis. 

Atropin.^ — Atropin  administered  hypodermically,  in  doses  of  -^  grain 
every  three  or  four  hours,  according  to  indications,  has  been  of  more 
service  than  ergot  or  digitalis.  Still,  in  some  cases  the  writer  has 
observed  an  increase  in  the  hemorrhage  soon  after  its  administration. 

Gelatin. — With  a  view  of  increasing  the  coagulative  power  of  the 
blood  gelatin  has  been  recommended  by  Dastre  and  Floresco.^    Four 

'  Jour.  Amcr.  Med.  Assn.,  1909,  liii,  1029. 

-Jour,  of  Pharmacol,  and  Exper.  Therap.,  1914,  vi,  13. 

3  Compt.  rend,  de  la  Soc.  de  biolog.,  1896,  iii,  243. 


HEMOPTYSIS  561 

to  6  ounces  of  a  sterilized  3  per  cent,  solution  of  gelatin  is  injected 
under  the  skin  of  the  abdomen  or  thigh.  Great  care  must  be  taken 
in  preparing  the  solution,  as  well  as  while  injecting  it  because  severe 
cases  of  sepsis,  even  tetanus,  have  been  reported.  Altogether  it  is 
not  a  harmless  procedure — it  is  painful,  leaves  painful  infiltrations 
at  the  site  of  the  injection,  often  provokes  fever,  and  is  followed  by 
urticarial  eruption.  If  gelatin  is  used  at  all  it  should  be  given  by 
mouth.  The  patient  may  be  given  jelly  made  from  calves'  legs,  etc., 
or  gelatin  may  be  mixed  with  milk;  or  a  concentrated  solution  may  be 
administered  per  rectum. 

Calcium  lactate,  acetate,  chloride,  etc.,  are  other  time-honored  rem- 
edies given  with  a  view  of  increasing  the  coagulability  of  the  blood 
in  doses  of  10  to  20  grams  repeated  four  to  six  times  a  day.  Their 
utility  is  doubtful;  all  that  may  be  said  about  them  is  that  they  are 
painless  and  harmless. 

Blood  Serum. — The  use  of  blood  serum  in  hemophilia  has  suggested 
its  application  in  hemoptysis  with  a  view  of  increasing  the  coagulability 
of  the  blood.  Horse  serum  may  be  used  in  doses  of  from  20  to  40  c.c. 
subcutaneously.  Inasmuch  as  at  present  diphtheria  antitoxin  is 
everywhere  available,  it  may  be  used.  But  manufacturing  chemists 
now  have  on  the  market  appropriate  preparations.  It  should  not  be 
used  at  long  intervals  several  times  for  fear  of  anaphylaxis.  I  have 
tried  it  several  times  and  was  not  favorably  impressed  with  it. 

Venesection.^With  a  view  of  producing  a  rapid  fall  in  the  blood- 
pressure  venesection  has  been  used  in  desperate  cases  of  pulmonary 
hemorrhage.  In  the  days  of  indiscriminate  bleeding,  this  was  one 
of  the  standard  therapeutic  measures,  but  even  at  present  many 
authors  recommend  it.  Bonney  recommends  it  when  the  blood- 
pressure  is  abnormally  high  even  in  small  initial  hemoptysis,  and  also 
in  bronchopneumonia  following  pulmonary  hemorrhage,  when  the 
right  heart  is  dilated  and  there  is  pulmonary  edema,  cyanosis  and 
coma.  More  recently  A.  G.  Shortle^  urged  this  method  again  in  cases 
in  which  the  bleeding  is  seriously  interfering  with  the  functions  of 
respiration.  "The  prompt  relief  to  the  impaired  respiration  is  not 
the  only  benefit  rendered  in  such  cases.  The  coughing  and  struggling 
for  breath,  with  the  coincident  inspiring  of  blood  and  sputum  into 
the  air  cells  is  also  stopped,  and  the  development  of  bronchopneumonia 
maybe  prevented."  In  persisting  hemorrhages  it  is  also  indicated,  ac- 
cording to  Shortle ;  "  it  is  safer  to  bleed  from  the  arm  than  from  the  lung." 

Of  course  this  is  rather  heroic  treatment,  and  involves  great  respon- 
sibility, especially  when  attending  to  patients  in  their  homes.  But  in 
the  desperate  cases  in  which  there  is  evidently  nothing  to  lose,  it  may 
be  given  a  trial  when  everything  else  has  failed. 

Diet  in  Hemoptysis. — In  cases  of  slight  hemoptysis  with  only  streaky 
sputum,  or  when  a  few  mouthfuls  of  blood  are  brought  up,  the  diet 

1  Trans.  Nat.  Assn.  Study  and  Prev.  of  Tuberc,  1915,  xi,  147. 
36 


562  SYMPTOMATIC   TREATMENT 

need  not  be  changed.  But  in  active  and  profuse  hemorrhage  all  solid 
and  hot  food  is  to  be  interdicted.  Inasmuch  as  the  first  indication 
is  to  reduce  the  blood-pressure,  we  must  restrict  the  quantity  of 
fluids  ingested.  Sudden  or  rapid  filling  of  the  bloodvessels  with  water 
increases  the  blood-pressure  and  may  lead  to  an  increase  in  the 
bleeding.  In  European  resorts,  where  phthisis  is  treated  with  mineral 
waters,  hemorrhagic  cases  have  been  excluded  ostensibly  for  the 
reason  that  excessive  ingestion  of  water  induces  hemorrhage.  In 
.  very  copious  hemorrhages,  fluids  should  be  given  only  for  the  purpose 
of  allaying  thirst — a  couple  of  ounces  at  a  time.  Swallowing  small 
pieces  of  ice  served  this  purpose  best.  Alcohol,  coffee  and  tea,  etc., 
should  be  discarded.  Milk,  eggs,  scraped  beef,  etc.,  may  be  given  in 
small  quantities  at  a  time. 

Twenty-four  hours  after  the  cessation  of  the  bleeding,  irrespective 
of  the  clots  expectorated  with  the  sputum,  we  may  begin  to  feed  the 
patient  guardedly.  The  general  condition  of  the  patient,  as  well  as 
the  concomitant  symptoms  should  be  our  guides.  A  cup  of  milk  every 
hour  or  two,  cream,  a  raw  egg,  and  some  scraped  beef  may  be  given. 
On  the  third  day  ordinary  feeding  may  be  resumed,  so  that  about 
five  or  six  days  after  the  hemorrhage  a  standard  dietary  is  reached. 

Convalescence. — During  convalescence,  even  if  there  is  no  fever,  or 
other  complications,  the  patient  is  to  be  kept  in  bed  for  five  or  six 
days  after  the  disappearance  of  all  traces  of  blood  from  the  expectora- 
tion. Resumption  of  exercises  should  be  allowed  gradually.  It  is 
best  that  for  two  or  three  weeks  after  even  a  moderate  hemorrhage 
the  patient  should  keep  at  comparative  rest.  The  cough  should  be 
carefully  controlled  during  that  period  and  exposure,  especially  to 
intense  sun  rays,  avoided.  Patients  who  show  a  proclivity  to  fre- 
quently recurring  hemorrhages  are  to  be  warned  against  all  physical 
and  mental  excesses,  and  alcohol  is  to  be  strictly  prohibited. 

Dyspnea. — We  have  seen  that  subjective  dyspnea  is  rare  in  many 
cases  of  chronic  phthisis,  and  that  the  patients  are  only  rarely  short- 
winded,  if  at  all.    In  some  cases  this  symptom  demands  treatment. 

Toxic  dyspnea,  due  to  progressive  disease  of  the  lung,  is  best  treated 
by  rest.  It  is  always  accompanied  by  fever  and  the  treatment  directed 
to  remove  the  pyrexia  usually  helps  along  in  the  direction  of  relieving 
the  air  hunger.  During  acute  exacerbations  in  the  course  of  chronic 
phthisis,  toxic  dyspnea  is  very  frequent  and  the  treatment  is  clearly 
defined. 

Dyspnea  is  often  due  to  some  preexisting  disease.  This  is  the  case 
with  pulmonary  emphysema,  asthma,  cardiac  and  renal  disease.  .  The 
treatment  is  that  of  the  underlying  pathological  condition.  In  those 
having  emphysema  or  asthma,  the  iodides  are  very  often  of  immense 
help,  provifled  there  is  no  tendency  to  hemoptysis.  For  the  nocturnal 
attacks  of  dyspnea,  morphin  or  heroin  may  have  to  be  given. 

Dyspnea  may  be  due  to  some  acute  or  subacute  complication, 
such  as  pleurisy,  with  or  without  effusion,  spontaneous  pneumothorax, 


INSOMNIA  563 

etc.  The  treatment  is  considered  in  the  sections  deaHng  with  these 
compUcations.  In  the  terminal  stages  of  the  disease  the  air  hunger 
may  only  be  relieved  by  large  doses  of  morphin  or  heroin  and  no  patient 
should  be  denied  these  solacing  remedies.  The  dangers  of  habit 
formation  should  not  be  thought  of  at  this  stage  of  the  disease. 

Cardiac  Weakness. — Patients  who  suffer  from  tachycardia  or  car- 
diac palpitation,  permanent,  or  provoked  by  mild  exertion  or  excitement, 
must  be  kept  at  perfect  rest  in  bed.  Smoking  and  the  consumption 
of  alcohol  and  coffee  are  to  be  interdicted  and  all  forms  of  nervous 
and  emotional  excitement  are  to  be  avoided.  At  times  these  cardiac 
disturbances  are  due  to  gastric  derangement  and  may  call  for  modi- 
fications in  the  quantity  and  quality  of  the  food. 

In  many  cases,  especially  in  the  advanced  stages,  palpitation  is  due 
to  cardiac  displacement,  especially  in  left-sided  lesions  in  which  the 
heart  is  drawn  upward  and  to  the  left.  Rest  is  the  only  remedy  we 
have  for  this  condition. 

From  whatever  cause  cardiac  weakness  arises,  it  may  at  times 
become  acute;  collapse  is  not  uncommon  after  some  excitement  or 
overexertion.  Now  and  then  a  patient  dies  suddenly  as  a  result  of 
heart  failure.  For  collapse,  hot  drinks  of  whisky,  warm  applications 
to  the  extremities,  and  some  stimulants  like  camphor,  strychnin,  etc., 
are  to  be  administered  hypodermically. 

In  the  far-advanced  stages  there  is  acute  dyspnea,  cyanosis,  and 
edema  owing  to  cardiac  failure  resulting  from  the  extensive  lesion, 
toxemia,  etc.  These  terminal  symptoms  are  treated  with  digitalis, 
though  in  my  experience  this  drug  has  very  little  influence  on  the  heart 
at  this  stage.  In  most  cases  the  subjective  feeling  of  weakness  and  air 
hunger  are  best  relieved  by  liberal  doses  of  morphin,  or  heroin. 

Insomnia. — In  phthisical  patients  insomnia  may  be  due  to  various 
causes  and  it  is  not  advisable  to  resort  to  soporific  medication  in  every 
case.  Rest  and  fresh  air  in  the  sleeping  room  may  induce  sleep; 
so  may  avoidance  of  a  heavy  meal  late  in  the  evening,  a  warm  bath 
before  retiring,  etc.  These  means  will  suffice  in  most  of  incipient 
cases  in  which  the  sleeplessness  is  due  to  worry  on  account  of  the 
seriousness  of  the  ailment. 

In  incipient  cases  insomnia  may  be  due  to  the  cough  which  keeps 
the  patient  awake,  and  the  indications  are  those  discussed  when  speak- 
ing of  the  treatment  of  cough.  When  due  to  digestive  disturbances, 
it  is  to  be  treated  accordingly.  In  the  advanced  stages  it  is 
often  due  to  the  fact  that  the  patient  is  lying  at  perfect  rest  during 
the  whole  day,  and  sleeps  several  hours  for  an  hour  or  so  at  a  time. 
The  patient  is  then  to  be  kept  awake  during  the  day.  In  some  cases 
hypnotic  drugs  must  be  given,  and  of  these  sulfonal  or  trional,  in  10- 
to  15-grain  doses,  may  be  administered;  3  to  6  grains  of  veronal  will 
serve  the  purpose  in  some  cases.  If  the  treatment  has  to  be  prolonged, 
the  drugs  may  have  to  be  alternated.  In  the  far-advanced  stages  only 
large  doses  of  morphin  may  give  relief. 


564  SYMPTOMATIC  TREATMENT 

Pains  in  the  Chest. — Most  of  the  pains  in  the  chest  complained  of 
by  tuberculous  patients  may  be  relieved  by  the  administration  of  some 
placebo  or  the  application  of  a  mustard  plaster,  dry  cupping,  tincture 
of  iodin,  etc.  In  some  cases  it  is  necessary  to  administer  some  of  the 
coal-tar  analgesics  or  salicylates.  Small  doses  of  antipyrin,  phenacetin, 
pyramidon,  etc.,  with  caffein  may  be  given.  Sodium  salicylate  or 
aspirin  gives  relief  in  many  cases.  But  on  rare  occasions  we  meet 
with  patients  in  whom  the  pains  in  the  chest  are  so  severe  as  to  require 
the  administration  of  a  dose  of  codein  or  morphin.  When  due  to 
intercurrent  pleuris}^,  strapping  of  the  chest  with  adhesive  plaster  is 
indicated.  The  pains  in  the  shoulder,  which  are  very  acutely  felt 
especially  during  the  night,  are  very  difficult  to  manage.  The  coal- 
tar  analgesics  and  the  salicylates  usually  give  no  relief,  and  often 
even  safe  doses  of  morphin  fail.  Hot  applications  to  the  affected 
part,  or  rarely  the  actual  cautery,  may  be  necessary. 

Anorexia. — Many  patients  have  a  good  appetite:  even  when  the 
fever  is  comparatively  high  the  desire  for  food  may  be  retained, 
which  is  not  observed  in  other  febrile  diseases.  But  in  others  it  is 
defective  or  inadequate  to  induce  them  to  ingest  a  sufficient  quantity 
of  food  for  the  replenishment  of  the  inroads  on  their  bodies  made  by 
the  the  disease.  It  has  been  my  experience  that  their  number  is  not 
very  large  among  those  who  are  well  instructed  along  the  line  of 
proper  food  and  nourishment. 

Medicinal  treatment  is  not  the  first  thing  to  give  in  anorexia.  Out- 
door life,  regulated  exercises,  regularity  of  meals,  etc.,  suffice  in  most 
cases  to  improve  the  appetite  to  the  desired  degree.  In  many  it  will 
be  found  that  dietetic  errors  are  at  the  bottom.  The  traditional  and 
stereotyped  advice  "plenty  of  milk  and  eggs"  given  indiscriminately, 
is  more  responsible  for  disgust  for  food  than  any  other  single  factor. 
Drinking  two  or  even  three  quarts  of  milk  a  day,  and  swallowing 
six  to  twelve  raw  or  soft-boiled  eggs,  overload  and  often  dilate 
the  stomach,  produce  congestion  of  the  liver,  and  create  a  disgust  for 
all  kinds  of  food.  While  some  patients,  who  may  be  considered 
dietetic  curiosities,  may  keep  up  with  such  a  regime  for  weeks  and 
even  gain  in  weight,  in  the  vast  majority  the  digestive  organs  revolt, 
the  palate  loses  its  taste  for  food  altogether  and,  coupled  with  diarrhea 
or  constipation,  the  functions  of  assimilation  fail. 

In  this  class  of  patients  we  may  note  with  satisfaction  a  remarkable 
change  soon  after  the  quantity  of  milk  and  eggs  is  reduced,  or  they  are 
altogether  discarded  for  a  time.  We  must  never  neglect  to  tell  our 
patients  that  as  long  as  the  appetite  and  digestion  are  good,  they  need 
not  make  any  changes  in  their  accustomed  diet,  excepting  perhaps  to 
increase  the  quantity,  which  is  very  desirable.  With  a  variety  of  food- 
stuffs it  is  usually  easy  to  consume  more  than  before  the  onset  of  the 
disease.  Instructions  along  the  lines  of  good  cooking  should  ne^'er  be 
neglected.  x\mong  the  poor  and  moderately  well-to-do  it  has  been  my 
habit  to  send  for  the  mother,  wife,  or  sister  of  the  patient  and  urge  her 


GASTRIC  DISTURBANCES  565 

to  exercise  special  care  in  the  preparation  of  the  food  and  to  cater  to 
the  palate  of  the  patient.  The  person  who  has  prepared  food  for  the 
patient  for  a  long  time  knows  best  what  he  will  relish.  Of  course  the 
teeth  are  to  be  examined  and  repaired  in  case  caries  are  found,  and 
proper  instructions  as  to  mastication  are  to  be  given. 

In  most  cases  the  appetite  can  be  improved  by  corrections  of  any 
of  the  just  mentioned  errors  without  any  medication  at  all.  All  are 
to  be  told  in  plain  language  that  their  only  chance  for  recovery  lies 
in  consuming  proper  food  and  plenty  of  it;  that  they  can  best  be  cured 
through  their  stomach,  and  that  they  must  eat  even  if  the  desire  for 
food  is  not  at  its  best.  This  often  has  the  desired  effect.  When  the 
patient  finds  that  with  proper  food  he  gains  in  weight  he  is  encour- 
aged to  eat  more.  The  gain  in  weight  is  usually  seen  best  during  the 
first  month  or  two,  but  after  a  considerable  increase  the  gain  slackens. 
As  long  as  he  holds  his  own  at  his  former  weight,  or  little  above,  there 
is  nothing  to  worry  about. 

Gastric  Disturbances. — ^In  some  cases  we  must  resort  to  medication 
to  provoke  an  appetite.  I  consider  creosote  as  the  drug  which  acts 
the  best.  Small  or  moderate  doses  of  creosote  or  any  of  its  derivatives 
- — creosote  carbonate,  guaiacol,  guaiacol  carbonate,  etc. — may  be 
given  and  the  appetite  and  digestion  promptly  improve.  In  others 
we  may  give  bitter  tonics — the  tinctures  of  nux  vomicee,  condurango, 
cinchona,  etc.  Orexin  tannate  is  also  good  in  5-grain  doses  in  powder 
or  tablet  form  taken  half  an  hour  before  meals.  When  there  is  diar- 
rhea, this  drug  is  very  good.  I  have  used  the  following  with  good 
results : 

I^ — Tinct.  nucis  vomicae 5i.i  8-0 

Acid,  nitrohydrochlorici  dilut Siij  12.0 

Tinct.  gentianse  comp gij  64.0 

Tinct.  cardamomi  comp q.  s.  ad      5iv  120.0 

M.     S. — One  teaspoonful  well  diluted  in  water  three  times  a  day  before  meals. 

The  nux  vomica  may  be  replaced  by  condurango  and  the  nitro- 
hydrochloric  acid  omitted  in  cases  in  which  they  are  contra -indicated. 
In  obstinate  cases  stomachic  medicaments  are  to  be  changed  often. 

In  hyperacidity  dietetic  changes  are  to  be  made  according  to  indi- 
cations, and  it  is  always  to  be  borne  in  mind  that  it  may  be  due  to 
overfeeding.  Often  medication  is  necessary.  I  have  had  good  results 
with  the  following: 

I^ — Magnesii  oxidi 5iv  16.0 

Sodii  bicarbonatis ■       •       •       ■       3j  32.0 

Extracti  belladonnas gr.  ij  0.13 

M.  ft.  chart.  No.  xxiv  div. 

S. — One  powder  three  times  a  day  after  meals. 

Or  the  following  effervescent  powder  may  be  given:  30  grains  of 
bicarbonate  of  sodium  in  one  powder,  and  10  grains  of  tartaric  acid 
in  another.  Each  of  these  is  to  be  dissolved  in  half  a  tumbler  of  water, 
then  added  one  to  the  other  and  swallowed  during;  effervescence. 


566  SYMPTOMATIC   TREATMENT 

Some  are  relieved  by  a  tablet  of  y^^  grain  of  atropin  sulphate  given 
after  meals. 

Constipation. — Constipation  is  another  of  the  troubles  of  the  phthis- 
ical which  often  interferes  with  the  fa^'orable  progress  of  the  case. 
It  is  best  combated  by  proper  dietetic  measures,  especially  increasing 
the  quantity  of  fruits  and  vegetables,  fresh  and  cooked.  But  mildly 
laxative  drugs  must  be  given  in  many  cases.  Before  giving  them 
we  must  make  sure  that  it  is  not  one  of  the  anodyne  drugs,  codein, 
morphin,  dionin,  etc.,  which  is  responsible.  Phenophthalein  appears 
to  be  the  best,  and  3  to  5  grains  may  be  given,  and  next  to  it  cascara 
sagrada  in  appropriate  doses. 

In  the  advanced  stages,  when  diarrhea  is  apt  to  alternate  with  con- 
stipation, laxative  drugs  are  to  be  used  with  caution.  They  may 
induce  an  uncontrollable  diarrhea.  It  is  always  better  to  first  try 
proper  changes  in  the  diet,  or  the  effects  of  some  special  food.  Thus, 
I  find  that  buttermilk  will  cause  a  movement  of  the  bowels  better 
than  any  medication  in  some  tuberculous  patients. 

Diarrhea. — We  have  seen  that  diarrhea  in  the  tuberculous  is  not 
always  due  to  ulcerations  in  the  intestines  and  that  the  latter  may 
exist,  while  the  patient  is  constipated.  In  many  cases  the  diarrhea  is 
due  to  chronic  catarrh  of  the  bowels  induced  by  swallowed  sputum 
and  the  patient  is  to  be  warned  against  this  very  bad  habit.  In 
others  it  is  due  to  consumption  of  large  quantities  of  raw  milk,  and 
this  must  be  corrected. 

In  case  the  diarrhea  is  due  to  tuberculous  ulceration  or  amyloid 
degeneration  of  the  intestines,  it  is  often  very  difficult  to  manage. 
The  patient  must  remain  in  bed  and  appropriate  changes  be  made 
in  the  diet.  Fluids  in  general  are  to  be  reduced  in  quantity,  especially 
cold  drinks.  The  great  majority  of  vegetables,  salads,  fruits — raw  or 
cooked — pastries,  rye  bread,  fats  and  sweets  are  to  be  avoided.  While 
most  patients  tolerate  milk  very  well,  there  are  many  who  do  not  and, 
in  obstinate  cases,  it  is  advisable  to  discard  it  for  a  few  days  and  watch 
the  effects.  Bouillon  and  soups  should  be  given  without  the  addition 
of  vegetables;  eggs,  butter,  scraped  or  finely  minced  beef,  boiled 
fish,  and  oysters  may  be  allowed,  but  no  lobster.  Of  the  vegetables 
allowed  the  following  may  be  mentioned:  Rice,  sago,  etc.,  boiled  in 
milk  or  served  with  cream,  mashed  potatoes,  etc. 

In  many  cases  medicinal  treatment  must  be  given  to  control  the 
frequent  stools.  The  ancient  "styptic"  remedies,  such  as  lead  acetate, 
iron,  alum,  etc.,  are  worthless  in  the  vast  majority  of  cases.  But  the 
modern  preparations  of  tannin,  such  as  tannigen,  tanalbin,  etc.,  are 
occasionally  of  service  in  lai^e  doses,  and  should  be  given  a  trial.  The 
subnitrate  of  bismuth  should  be  given  in  doses  of  10  to  15  grains  five 
or  six  times  a  day.  But  in  most  cases  opium  must  be  used,  more  or 
less.  Bismuth  or  tannigen  may  be  given  in  powders  combined  with 
fairly  large  doses  of  Dover's  powder,  or  the  official  tincture  of  opium 
in  5-  to  10-minim  doses  three  or  four  times  a  dav. 


DIARRHEA  567 

IJ— Tannigeni 5iij  12.0 

Bismuthi  subiiitratis 3v,i  24.0 

Resorcinolis gr.  ix  0.6 

M.  ft.  cachet  No.  xviii. 

S. — One  cachet  four  times  a  day. 

I^ — Bismuthi  subnitratis Sj  32.0 

Tinct.  opii  deodorati 3ij  8.0 

Aquae  cinnamoni q.s.  ad  3iv  120.0 

M.     S. — One  teaspoonfui  four  times  a  day. 

When  bismuth  subnitrate  fails  we  may  try  the  subgallate  in  10-  or 
15-grain  doses  with  or  without  opium.  There  are,  however,  many 
cases  in  which  everything,  even  the  administration  of  heroic  doses 
of  opium,  fails  to  stop  the  diarrhea  and  we  must  be  content  with 
relieving  the  pains. 

Some  of  these  patients  complain  of  tenderness  or  pain  in  the  abdo- 
men. This  is  best  relieved  by  hot  fomentations.  In  the  later  stages, 
when  emaciation  is  extreme,  the  extremities  are  to  be  kept  warm  and 
the  unfortunate  patient  should  not  be  denied  the  merciful  relief  of 
morphin  in  large  doses. 


CHAPTER  XXXIX. 

OPERATIVE  TREATMENT— ARTIFICIAL 
PNEUMOTHORAX. 

Historical  Note. — Spontaneous  pneumothorax  has  been  the  most 
dreaded  of  comphcations  of  phthisis  and  experience  has  taught  that 
the  vast  majority  of  patients  who  suffer  from  this  accident  succumb. 
But  some  have  observed  that  a  pneumothorax  may  be  what  the 
French  call  "providential"  and  exert  a  rather  salutary  influence  on 
the  symptoms  of  the  underlying  disease.  In  fact  as  far  back  as  1822 
James  Carson/  a  physiologist  at  Liverpool,  suggested  the  advisa- 
bility of  artificially  inducing  pneumothorax  in  phthisis  for  therapeutic 
purposes  and  performed  some  animal  experiments  with  a  view  of 
working  out  a  suitable  technic.  In  his  book  on  diseases  of  the  chest, 
published  in  1837,  that  acute  clinical  observer,  William  Stokes,^  has 
this  to  say:  "The  proper  symptoms  of  phthisis  are  in  many  cases 
arrested,  and  singularly  modified,  by  the  occurrence  of  the  new  disease 
(pneumothorax).  I  have  often  found  that  after  the  first  violent  symp- 
toms had  subsided,  the  hectic  ceased,  the  phthisical  expression  dis- 
appeared, the  flesh  and  strength  returned;  and  in  this  way  the  patient 
has  enjoyed  many  months  of  comfortable  existence,  and  was  only 
disturbed  by  dyspnea  and  the  sound  of  fluctuation  on  exercise." 
In  his  book  on  Diseases  of  the  Lungs,  published  in  1860,  Walter  Hayle 
Walshe^  says:  "In  some  recorded  cases  of  actively  advancing  phthisis, 
the  first  sufferings  of  accidental  perforation  having  passed,  it  has 
certainly  appeared,  though  the  signs  of  hydropneumothorax  remained, 
that  the  phthisical  symptoms  themselves  underwent  improvement. 
But  an  occurrence  so  rare  gives  no  warranty  for  the  fanciful  proposal 
to  treat  phthisis  by  producing  artificial  pneumothorax."  This  shows 
clearly  that  the  method  was  suggested  in  England  long  before  Forlanini 
has  done  it  in  Italy.  During  the  course  of  the  nineteenth  century 
many  other  physicians  have  reported  experiences  similar  to  those  of 
Stokes  and  Walshe  just  quoted. 

It  was,  however,  C.  Forlanini,^  of  Pavia,  who  first  induced  a  pneumo- 
thorax for  therapeutic  purposes  and  reported  his  experiences  in  1894. 
Independently  of  Forlanini,  John  B.  Murphy,'^  of  Chicago,  did  the 

1  The  Elasticity  of  the  Lungs,  Trans.  Roy.  Soc.  London,  1820;  Essays,  Physiological 
and  Practical,  Liverpool,  1822. 

2  A  Treatise  on  Dis.  of  the  Chest,  New  Sydenham  edition,  p.  455. 

3  A  Practical  Treatise  on  the  Diseases  of  the  Lungs,  American  edition,  Philadelphia, 
1860,  p.  250. 

^Gazz.  d.  osped.,  1882,  iii,  537,  585,  601,  etc.;  Gazz.  med.  di  Torino,  1894,  Ixv,  381, 
401. 

6  Jour.  Amer.  Med.  Assn.,  1898,  xxi,  151,  208,  281,  341. 


PRINCIPLES   UNDERLYING  THE   TREATMENT  569 

same  in  1898.  But  for  some  time  no  notice  was  paid  to  this  method 
of  treatment  until  Brauer,  Spengler,  and  some  others  took  it  up  in 
Germany.  At  present  it  is  one  of  the  recognized  methods  of  treat- 
ment of  certain  cases  of  pulmonary  tuberculosis.  That  it  is  a  valuable 
method  will  be  appreciated  when  it  is  borne  in  mind  that  it  is  mostly 
indicated  in  cases  in  which  everything  else  has  been  tried  and  found 
wanting;  in  other  words,  when  there  is  everything  to  gain  and  noth- 
ing to  lose.  Contrasted  with  other  methods  of  treatment,  which  are 
nearly  always  stated  to  exercise  their  alleged  curative  effects  only 
during  the  incipient  stage  of  the  disease,  when  diagnosis  is  often 
doubtful  and  spontaneous  cures  not  uncommon,  it  is  to  be  considered 
one  of  the  best  therapeutic  procedures  we  have  at  present  for  the 
cure  of  phthisis. 

Principles  Underlying  the  Treatment. — The  aim  is  to  introduce  into 
the  pleural  cavity  a  sterile  and  harmless  material  which  will  collapse 
the  lung  on  the  affected  or  more  affected  side  of  the  chest.  The  lung 
is  thus  put  at  rest  and  given  an  opportunity  to  heal.  We  have  already 
seen  that  functional  rest  is  as  important  in  phthisis  as  in  other  diseases. 
In  surgical  tuberculosis  rest  has  been  more  effective  as  a  curative  agent 
than  all  other  methods.  Rest  has  also  been  used  with  beneficial 
results  in  other  diseases,  notably  general  rest  in  functional  nervous 
diseases  as  was  worked  out  by  Weir  Mitchell;  tracheotomy  in  certain 
laryngeal  obstructions,  gastro-enterostomy  in  cancer  and  especially 
ulcer  of  the  stomach,  enterostomy  in  certain  diseases  of  the  lower 
bowels  and  rectum,  etc. 

The  lung  is  one  of  the  organs  of  the  body  which  never  rests  but 
expands  and  contracts  at  least  12,000  times  per  day  throughout 
life.  With  an  artificial  pneumothorax  we  can  place  one  lung  at  rest 
almost  as  effectively  as  the  splint  puts  at  rest  a  tuberculous  joint, 
without  endangering  the  life  of  the  patient.  Moreover,  the  lung  is 
the  only  organ  in  the  body  which  is  constantly  in  a  state  of  distention. 
Even  after  the  most  forced  expiration  it  does  not  collapse  utterly. 
Any  solution  in  continuity  in  the  pulmonary  tissues  remains  separated 
and  there  appears  to  be  no  tendency  to  bring  about  the  union  of  the 
diseased  parts  or  to  facilitate  the  process  of  healing  by  coaptation. 
Infiating  gas  into  the  pleural  cavity  and  collapsing  the  lung  we  achieve 
two  objects:  The  lung  is  immobilized  at  its  root,  and  it  is  compressed 
by  the  gas  in  the  pleural  cavity  and  the  retraction  of  its  elastic  tissues. 
Its  volume  is  greatly  reduced,  diseased  parts  and  walls  of  cavities  are 
brought  into  apposition,  so  that  they  may  cicatrize  by  the  formation 
of  connective  tissue. 

Pneumothorax  does  even  more  than  afford  rest  to  the  diseased  lung. 
By  compression  it  empties  the  lung  of  its  contents.  The  pus  and  cheesy 
detritus  in  cavities,  the  inflammatory  exudates  in  the  alyeoli  and 
bronchioles  are  all  squeezed  out  as  from  a  sponge,  removing  the  main 
source  of  toxic  absorption.  It  also  limits  the  diseased  focus  and  pre- 
vents its  spread,  so  that  the  healthy  parts  of  the  lung  remain  so  while 


570      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

the  lesion  is  in  time  converted  into  a  cicatrix,  or  is  encapsulated.  As 
a  result  of  drainage,  mixed  infection  is  eliminated  and  prevented.  The 
fact  that  the  air  current  entering  through  the  trachea  cannot  circulate 
within  the  collapsed  lung  tissues,  prevents  superinfection  of  healthy 
parts  of  the  organ  with  emboli  of  detritus  carried  from  one  part  to 
another  along  the  bronchial  tree  and  mixed  infection  with  micro- 
organisms other  than  tubercle  bacilli,  which  may  be  brought  in  with 
the  air  current,  is  avoided. 

The  circulation  of  the  blood  is  impeded  in  the  collapsed  lung,  but 
there  occurs  a  venous  or  passive  hyperemia  which  is  known  as  an  im- 
portant factor  in  the  defence  of  tissues  against  tubercle  bacilli.  The 
comparative  protection  against  tuberculosis  enjoyed  by  cardiacs  is 
ascribed  to  the  venous  hyperemia  of  the  lungs.  The  lymph  channels 
of  the  collapsed  lung  are  compressed,  as  has  been  shown  by  Shingu,^ 
who  subjected  animals  with  induced  pneumothorax  to  the  inhalation 
of  soot,  and  at  the  autopsy  found  that  the  collapsed  lung  remained 
free  from  soot.  Animals  were  compelled  to  inhale  large  quantities 
of  soot,  and  subsequently  pneumothorax  was  induced,  and  when  they 
were  finally  killed  it  was  found  that  the  free  lung  was  darker  than  the 
collapsed  lung.  This  tends  to  show  that  the  circulation  of  lymph, 
which  is  the  main  factor  in  removing  inhaled  particles  from  the  lung, 
is  impeded  or  arrested  because  of  stasis  of  lymph  in  the  compressed 
lung.  In  this  manner  the  absorption  of  toxins  from  the  lesions  into 
the  general  circulation,  is  impeded  or  arrested  in  pneumothorax,  the 
clinical  phenomena  of  phthisis,  such  as  fever,  nightsweats,  weakness, 
etc.,  are  prevented,  and  the  bod.y  is  thus  given  an  opportunity  to 
recuperate.  Moreover,  the  lymph  stream  being  unable  to  carry 
away  bacilli  from  the  lesion,  the  process  is  localized  to  the  affected 
areas.  These  points  have  been  found  clinically  and  at  the  autopsy 
table,  and  experimentally  by  Forlanini,-  Brauer,^  Saugman,  Graetz,^ 
Robinson  and  Floyd,^  Hamman  and  Sloan,*^  G.  M.  Balboni,^  Henry 
Schwatt,  Ralph  C.  Matson,  A.  G.  Shortle,  and  many  others. 

Technic. — The  technic  of  the  induction  of  a  pneumothorax  is  simple 
but  not  devoid  of  danger  and  even  fatal  accident.  The  object  is  to 
inject  gas  into  the  pleural  cavity,  and  not  anywhere  else.  Forlanini 
developed  a  technic  which  is  both  painless  and  bloodless.  Murphy, 
without  knowledge  of  Forlanini's  work,  developed  a  practically 
similar  technic.  Brauer  was  not  satisfied  that  the  Forlanini-Murphy 
method  is  safe  and  advocated  the  open  incision  method. 

The  Brauer  Method. — This  consists  in  incising  the  chest  wall,  dissect- 
ing down  to  the  pleura  by  cutting  through  the  fascia,  and  separating 

1  Beitr.  z.  Klinik  d.  Tuberkulose,  1908,  xi,  1. 

2  Ergebn.  d.  inner.  Med.  u.  Kinderheilk.,  1912,  ix,  621. 

3  Beitr.  z.  Klin.  d.  Tuberkul.,  1909,  xii,  49;    xiv,  419;    1911,  xix,  1. 
*  Ibid.,  1908,  x,  249. 

6  Arch.  Int.  Med.,  1912,  ix,  452. 

"  Johns  Hopkins  Hosp.  Bull.,  191.3,  xxiv,  264. 

'  Boston  Med.  and  Surg.  Jour.,  1914,  olxxi,  697,  955. 


TECHNIC 


571 


the  intercostal  muscles  with  a  blunt  instrument  in  the  direction  of 
their  fibers.  When  the  parietal  pleura  is  exposed,  it  is  punctured 
with  a  blunt  needle  or  cannula  and  the  gas  is  allowed  to  flow  in  by 
aspiration  of  the  pleural  cavity  or  by  pressure  when  indicated.  This 
method  has  failed  to  get  many  adherents  for  many  reasons.  But 
few  patients  want  to  submit  to  a  cutting  operation.  Then  there  is 
an  obvious  danger  of  sepsis  which  may,  of  course,  be  avoided  by  the 
usual  methodg.  I  have  found  no  reason  for  resorting  to  the  bloody 
operation  and  feel  confident  that  if  this  was  the  only  available  method 


Fig.  83. — Robinson's  modification  of   the  Brauer  apparatus  for  inducing  pneumothorax. 


of  inducing  an  artificial  pneumothorax  we  should  find  very  few  patients 
willing  to  submit. 

Very  few  now  practise  this  open  incision  method  and  most  of  those 
who  do  it  make  use  of  it  only  occasionally  when  the  Forlanini  method 
fails  because  of  pleural  adhesions. 

The  Forlanini-Murphy  Method.- — It  consists  in  a  simple,  bloodless 
puncture  of  the  chest  wall  with  an  especially  constructed  hollow 
needle  which  is  connected  with  a  gas  reservoir  and  a  water  manometer 
through  a  T-shaped  tube.  When  the  lumen  of  the  needle  punctures 
the  costal  pleura  the  gas  is  allowed  to  flow  into  the  pleural  cavity  by 


572      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 


THE  KNY  5CHEERER  CO. 


Fig.  84. — Forlanini-Saugman-Muralt  apparatus  for  the  induction  of  pneumothorax. 
This  apparatus  consists  in  the  main  of  two  glass  tubes,  twenty-four  and  a  half  inches 
high  and  about  two  inches  in  diameter  and  a  U-shaped  manometer  tube,  the  latter  filled 
with  an  alcoholic  solution  of  methj-lene-blue  and  mounted  in  the  centre  of  the  board  in 
front  of  a  graduated  porcelain  scale.  The  two  large  tubes  are  joined  by  means  of  rubber 
tubing  under  the  base  .4.  The  tube  to  the  left  is  graduated  to  1000  c.c.  and  the  other 
is  plain.     They  are  filled  with  water  up  to  500  c.c. 

The  graduated  tube  to  the  left  is  filled  from  the  tank  -nith  the  gas  to  be  introduced 
into  the  pleural  cavity,  and  the  gas  displaces  the  water  wliich  rises  correspondinglj'  in 
the  large  plain  tube  to  the  right. 

When  filling  the  apparatus  with  gas,  the  rubber  tubing  from  the  tank  is  to  be  con- 
nected with  a  rubber  gas-bag  to  the  opening  below  the  stopcock  C. 

Stopcock  D  should  stand  vertically. 

Stopcock  C  should  be  turned  so  as  to  connect  through  the  filter  and  into  the  graduated 
cylinder. 

Stopcock  E  on  the  top  of  the  non-graduated  tube  should  be  turned  so  as  to  allow  the 
air  in  this  tube  to  escape  when  the  gas  forces  the  water  into  it.  ^^'h(■Il  The  graduated 
cylinder  is  full  of  gas,  stopcock  C  should  be  closed. 


TECHNIC  ■  573 

the  suction  or  negative  pressure  in  that  cavity,  as  well  as  by  some 
positive  pressure  which  must  at  times  be  used  at  the  gas  reservoir. 

Simple  as  this  operation  appears  to  be,  there  are  certain  difficulties 
to  be  overcome  and  dangers  to  be  avoided.  The  main  difficulty  is  to 
pass  the  needle  as  far  as  the  costal  pleura,  puncture  it,  and  avoid  pene- 
trating the  visceral  pleura  and  the  lung.  The  dangers  are  mainly  in 
allowing  the  gas  to  flow  into  places  other  than  the  pleural  cavity, 
especially  into  a  bloodvessel  thus  causing  gas  embolism  which,  while 
not  invariably  fatal,  yet  is  sufficiently  menacing  to  be  dreaded  by  all 
who  are  doing  this  sort  of  operation. 

Apparatus. — To  avoid  this  accident  various  forms  of  apparatus 
have  been  invented.  As  is  usual,  they  are  all  based  on  one  main 
principle — ^the  manometer  which  was  introduced  by  Saugman.  Each 
apparatus  consists  primarily  of  two  graduated  bottles  connected 
by  tubing,  one  containing  the  gas  to  be  injected  and  the  other  some 
fluid,  so  that  the  fluid  flows  from  its  container  into  the  other  bottle, 
displacing  the  gas  which  is  sucked  or  pressed  into  the  pleural  cavity 
through  a  tube  and  an  especially  constructed  needle.  This  last  men- 
tioned tube  is  T-shaped  or  provided  with  a  three-way  stopcock,  of 
which  one  limb  communicates  with  the  gas  bottle,  the  second  with  the 
needle,  and  the  third  with  the  manometer.  At  any  moment  during 
the  operation  we  can  open  or  close  the  tube  leading  to  the  manometer 
or  the  gas  reservoir. 

As  has  been  said,  all  the  instruments  for  the  induction  of  a  pneumo- 
thorax are  constructed  on  this  simple  principle,  but  it  is  amazing  how 
some  have  succeeded  in  complicating  it  by  adding  various  attachments 
which  make  them  unwieldy  and  easily  disordered.  The  experience 
that  a  machine  in  order  to  be  successful  must  be  of  the  simplest  con- 
struction consistent  with  efficiency,  holds  good  here.  I  have  been 
using  Forlanini's  apparatus  as  modffied  by  Saugman^  and  von  Muralt,^ 
(Fig.  84)  and  also  the  Robinson  apparatus  (Fig.  83). 

The  Function  of  the  Manometer. — The  entire  safety  of  the  apparatus 
lies  in  the  manometer  which  has  been  called  by  Edward  von  Adelung'' 

1  Beitr.  z.  Kliiiik  d.  Tuberkulose,  1914,  xxxi,  571.  2  Ibid.,  1910,  xviii,  359. 

3  Jour.  Amer.  Med.  Assn.,  1914,  xlii,  1914. 


Funnel  F  connected  with  the  manometer  tube  serves  for  the  filling  of  the  manometer 
tube  to  zero  with  an  alcoholic  solution  of  methylene-blue. 

The  graduated  glass  tube  is  connected  with  the  glass  tube  B  which  is  filled  with 
sterilized  gauze  and  serves  as  a  filter.  The  three-way  stopcock  C  connects  with  the 
manometer  as  well  as  the  gas  cylinder,  thus  showing  the  oscillations  when  the  needle  is 
in  the  pleural  cavity.  When  stopcock  D  is  turned  horizontally  it  permits  the  mano- 
metric  reading  showing  the  degree  of  oscillation  while  the  gas  is  still  flowing. 

After  the  needle  has  been  properly  inserted  into  the  pleural  cavity  and  stopcock 
C  turned  to  the  graduated  tube,  the  gas  will  be  forced  out  by  the  weight  of  water  which 
is  contained  in  the  plain  tube.  When  extra  pressure  is  required,  a  small  rubber  tube  is 
connected  with  the  plain  tube,  so  that  the  remaining  water  may  be  gently  forced  into 
the  graduated  tube. 

The  manometric  scale  is  divided  into  50  centimetei's,  25  above  and  25  below  zero, 
indicating  respectively  negative  and  positive  pressure. 


574      OPERATIVE   TREATMENT— ARTIFICIAL   PNEUMOTHORAX 

the  heart  of  the  apparatus.  While  the  needle  passes  through  the  skin, 
subcutaneous  tissue,  muscles,  and  fascia  before  the  piercing  the  costal 
pleura,  the  manometer  records  atmospheric  pressure,  but  as  soon  as 
it  enters  the  pleural  cavity  the  air  in  the  connecting  tube  becomes 
rarefied  because  the  vacuum  in  the  pleural  cavity  aspirates  its  air 
content,  and  the  fluid  in  the  closed  limb  of  the  manometer  is  sucked  up 
toward  the  needle,  i.  e.,  from  the  open  into  the  closed  limb  and  a  dis- 
tinct difference  in  the  levels  of  the  fluid  is  evident.  Moreover,  when 
the  lumen  of  the  needle  is  really  in  the  pleural  cavity  the  respiratory 
movements  of  the  lung  are  recorded  in  the  manometer  which  shows 
distinct  oscillations  of  the  levels  of  its  fluid. 

This  explanation  of  the  work  of  the  manometer,  which  is  found  in 
most  works  on  the  subject,  is  unsatisfactory.  The  fact  is  that  normally 
there  is  no  pleural  cavity  at  all  because  the  parietal  and  visceral  pleura 
lie  tightly,  one  on  another;  nor  can  we  speak  of  negative  pressure  be- 
tween the  two  pleural  sheets  because  the  word  'pressure"  is  here  used 


Fig.  85. — Brauer- Floyd-Robinson  needle. 

in  the  sense  of  gas  pressure  which  can  be  measured  with  a  manometer ; 
but  such  a  negative  pressure  does  not  exist  between  the  two  pleural 
sheets.  The  manometric  readings  when  the  lumen  of  the  needle  is  in 
the  pleura  are  better  explained  by  Brauer,  Piery,^  and  ^Nloritz^  in  the 
following  fashion:  The  lung  must  be  considered  as  an  organ  fixed  at 
its  root  and  kept  in  a  state  of  equilibrium  by  the  pressure  of  the  atmos- 
pheric air  within  the  air  passages  and  by  the  elastic  tension  of  its  tissues. 
There  is  a  constant  tension  of  the  lung  from  the  roots  to  the  periphery 
at  the  thoracic  walls.  The  force  of  this  traction  is  equal  to  the  absolute 
elastic  tension  in  the  given  direction,  minus  the  atmospheric  pressure 
which  prevails  within  the  air  j)assages  and  so  prevents  its  collapse 
or  retraction  from  the  periphery  to  the  hilus.  The  intrapleural  press- 
ure, therefore,  never  differs  much  from  the  atmospheric  pressure,  as 


>  La  pratique  du  pneunioth(jrax  artififiel  en  phlhisiothcrapie,  Paris,  1912. 
-  Miinch.  med.  Wchnschr.,  1914,  Ixi,  1321. 


TECHNIC 


575 


has  been  shown  by  W.  Parry  Morgan/  and  in  consequence  any  gas 
drawn  into  the  cavity  will  not  be  appreciably  rarefied.  The  volume  of 
gas  which  will  have  passed  from  the  connecting  tube  into  the  pleural 
cavity  will  be  practically  equal  to  the  amount  of  fluid  which  will  have 
passed  from  the  open  to  the  closed  limb  of  the  manometer.  This 
volume  would,  when  the  negative  pressure  stands  at  15  cm.  of  fluid  in 
a  manometer  tube  of  0.3  cm.  bore,  measure  less  than  1  c.c. 

This  is  enough  to  separate  the  sheets  of  the  pleura,  if  there  are  no 
adhesions.  But  owing  to  the  elastic  tension  of  the  lung  and  the 
atmospheric  pressure  within  the  air  passages, 
there  is  actually  shown  a  negative  pressure  in 
the  manometer.  A  little  reflection  will  explain 
why  this  negative  pressure  will  be  stronger  dur- 
ing inspiration  because  of  the  greater  distance 
at  that  period  between  the  root  and  the  per- 
iphery, and  less  during  expiration.  With  the 
increase  in  the  quantity  of  gas  introduced  into 
the  pleural  cavity  the  tension  of  the  lung  will 
obviously  decrease  and  with  it  the  negative 
pressure,  until  finally  a  point  is  reached  when 
the  pressure  in  the  gas-containing  pleural  cavity 
is  0  and  later  even  becomes  positive. 

Bearing  in  mind  these  simple  principles  of  the 
manometer,  we  are  in  a  position  to  guard  against 
the  most  important  of  the  accidents  which  are 
liable  to  happen  during  the  operation.  In 
patients  with  pleural  cavities  free  from  adhe- 
sions, ordinary  and  careful  attention  to  the 
manometer  will  suffice  to  guard  against  mishaps. 
The  manometer  shows  conclusively  whether  the 
lumen  of  the  needle  is  in  the  pleural  cavity  or 
not.  It  also  gives  reliable  information  as  to  the 
state  of  the  pleural  cavity  with  particular  refer- 
ence to  adhesions,  showing  whether  they  are 
dense  and  extensive,  or  of  slight  extent  and 
may  be  separated  and  broken  up  by  an  increase 
in  the  intrapleural  pressure  with  the  gas.  Dur- 
ing the  course  of  the  treatment  we  are  able  to  ascertain,  with  the 
aid  of  the  manometer,  whether  the  nitrogen  has  been  absorbed  and  a 
refill  is  necessary;  whether  the  lung  has  been  completely  immobilized 
or  has  remained  expansile.  When  it  is  found  that  the  intrapleural 
pressure  increases,  and  this  cannot  be  attributed  to  excessive  gas 
insufflations,  it  indicates  pleural  effusion.  The  difficulties  in  cases 
with  pleural  adhesions  will  be  discussed  later  on. 

The  Gas  Used  for  Inflation. — Because  it  was  supposed  that  when 
oxygen  is  injected  into  the  pleural  cavity  it  is  quickly  absorbed,  and 

1  Lancet,  1914,  ii,  90. 


Fig.  86. — Saugman 
needle. 


576      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

that  nitrogen  will  remain  within  that  cavity  for  a  longer  time,  this 
element  was  selected  and  most  operators  use  it.  But  further  experience 
has  shown  that  atmospheric  air  is  just  as  good.  Webb,  Gilbert,  James 
and  Haven,^  and  Tobiesen^  have  shown  clinically  and  experimentally 
that  nitrogen  has  little,  if  any,  advantage  over  atmospheric  air, 
because  in  either  case  diffusion  of  gases  occurs  so  rapidly  that  within 
a  few  hours  the  proportion  of  the  two  gases,  nitrogen  and  oxygen,  is 
about  the  same.  For  this  reason  there  is  no  necessity  for  using  nitro- 
gen. Air  does  just  as  well.  Nitrogen  is  rather  expensive  when  bought 
in  tanks  from  manufacturers,  and  while  most  of  the  apparatus  for  the 
production  of  pneumothorax  is  portable,  the  large  iron  tank  of  nitro- 
gen is  not  easily  transported,  and  atmospheric  air  is  to  be  given 
preference  in  private  practice. 

The  Selection  of  the  Point  for  Injection. — The  first  inflation  must  be 
carefully  done  and  it  is  important  to  select  a  point  to  introduce  the 
needle  where  no  adhesions  are  likely  to  be  encountered.  Bearing  in 
mind  the  anatomy  of  the  chest  and  its  viscera  it  is  evident  that  the  ideal 
point  is  along  the  anterior  or  posterior  axillary  lines,  especially  at  the 
ninth  intercostal  space  posteriorly  for  apical  lesions,  or  in  the  third 
intercostal  space  just  outside  the  mammillary  line  for  lesions  of  the 
lower  lobes.  Of  course,  when  we  are  free  to  choose,  areas  covered  with 
thick  muscles  or  the  thick  mammary  gland  in  women  are  to  be  avoided. 
But  we  are  not  always  free  to  choose,  and  any  point  must  serve  our 
purpose  when  the  elective  places  are  not  available  because  of  adhesions. 
It  must  also  be  emphasized  that  it  is  very  difficult,  often  impossible, 
to  avoid  pleural  adhesions  with  all  the  means  of  diagnosis  at  present 
at  our  command. 

We  are  generally  guided  by  the  following  principles:  The  chest 
is  punctured  as  far  as  possible  away  from  the  main  pulmonary  lesion 
because  pleural  adhesions  are  most  likely  to  be  encountered  over 
the  diseased  lung  and,  what  is  more  important,  while  puncturing 
the  lung  is  ordinarily  harmless,  in  such  places  the  needle  may,  how- 
.  ever,  penetrate  cavities  and  produce  a  pyothorax.  But  adhesions 
are  found  everywhere  and  often  where  we  least  expect  them.  Physical 
diagnosis  is  apt  to  prove  misleading  and  the  fluoroscope  and  skiagraphy 
just  as  often  may  fail  to  reveal  them.  I  have  met  with  cases  in  which 
the  skiagraph  showed  all  the  conventional  signs  of  pleural  adhesions 
but  puncture  revealed  a  free  pleura  and  complete  collapse  was  easily 
obtained  with  three  or  four  inflations.  More  often  yet  the  skiagraph 
shows  a  clear  picture  and  it  is  conluded  that  the  pleura  is  free,  but 
puncture  shows  conclusively  that  there  are  adhesions. 

Forlanini  is  guided  by  tidal  percussion  of  the  margin  of  the  lung, 
especially  at  the  base.  When  he  finds  that  the  base  line  in  the  axilla 
shifts  between  10  and  12  cm.  during  extreme  inspiration,  as  compared 
with  extreme  expiration,  he  is  convinced  that  the  pleura  is  free.    Good 

»  Arch.  Int.  Med.,  1914,  xiv,  883. 
•^Brauer's  Beitrage,  1911,  xxi,  109. 


PLATE  XVII 


Fig.  1 


Fig.  2 


Complete  pneumothorax  in  right  pleural 
cavity,  but  there  are  several  bands  of 
adhesions  running  from  the  mediastinum 
to  the  diaphragm.  Left  lung  shows 
moderate  peribronchial  infiltrations  and 
a  few  calcified  glands  at  the  hilus.  Lower 
two-thirds  markedly  emphysematous. 


Spontaneous  pneumothorax  following 
first  inflation  in  an  attempt  at  creating 
an  artificial  pneumothorax  in  left  pleura. 
Diffuse  peribronchial  infiltration  through- 
out right  lung.  Heart  dropped,  slightly 
displaced  to  the  right.  Pleuropericardial 
adhesions  on  left  side. 


Fig.  3 


Incomplete  pneumothorax  in  upper  part  of  the  right  pleura.  Owing  to  dense 
adhesions  no  more  gas  could  be  injected  and  the  treatment  was  discontinued.  Note 
the  stomach  at  the  left  diaphragm. 


PLATE  XVIII 


Fig.  1 


Fig.  2 


Complete  pneumothorax  of  the  left 
pleura.  The  right  lung  shows  diminished 
aeration  owing  to  fine,  nodular  infiltra- 
tion and  also  to  engorgement.  Medias- 
tinum completely  displaced  to  the  right. 


Complete  pneumothorax  of  the  left 
pleura  with  displacement  of  the  heart  to 
the  right. 


Fig  3 


Fig.  4 


Darkness  of  right  lung  due  to  intense 
congestion  after  induction  of  a  pneumo- 
thorax, excepting  at  the  hilus,  where  it 
is  due  to  enlarged  glands  and  peribron- 
chial infiltrations.  One-half  of  the  left 
pleura  if  filled  with  air,  but  the  collapse 
of  the  lung  was  not  effective  in  compress- 
ing a  cavity  with  thick  walls,  situated  in 
the  first  and  second  interspaces.  Medias- 
tinum displaced  to  the  right. 


Pneumothorax  localized  in  upper  and 
lower  portions  of  left  lung,  but  separated 
by  pleural  adhesions  at  about  the  fourth 
rib,  where  also  a  cavity  with  dense  walls 
is  seen.  These  adhesions  have  interfered 
with  the  success  of  the  pneumothorax. 


TECHNIC  577 

mobility  of  the  lung  margins  is  the  most  important  sign  of  freedom 
from  pleural  ashesions,  according  to  Forlanini,  but  he  adds  that 
immobility  is  not  a  sure  sign  of  such  adhesions,  and  of  obliteration  of 
the  pleural  cavity.  There  are  cases  of  extensive  hepatization  of  the 
lung  in  which  the  mobility  of  the  lung  margin  is  defective  or  absent, 
yet  the  pleural  cavity  is  free.  Robinson  and  Floyd  also  consider  per- 
cussion the  most  reliable  guide  and  they  say  that  the  area  presenting 
a  note  nearest  approaching  the  normal  resonance  is  most  likely  ta  be 
free  of  adhesions,  while  von  Adelung  seeks  an  area  which  is  resonant 
and  yields  breath  sounds. 

It  appears  that  the  most  reliable  means  of  ascertaining  whether 
or  not  the  pleura  is  free  is  the  attempt  to  enter  it  with  the  needle 
connected  with  a  manometer.  In  case  the  first  puncture  does  not  yield 
negative  pressure  in  the  manometer — a  very  frequent  occurrence,  so 
that  when  one  enters  successfully  with  the  first  puncture  he  considers 
himself  lucky — another  attempt  is  made  at  a  different  point.  I  have 
made  in  one  case  four  punctures  before  succeeding  in  entering  the 
pleural  cavity  and  in  another  twelve  before  giving  up  the  case  as  not 
suitable  for  the  treatment.  Forlanini  made  fifteen  punctures  in  one 
case  before  he  finally  succeeded. 

The  skin  at  the  site  selected  for  puncture  is  painted  with  tincture 
of  iodiri  and  the  excess  is  washed  away  with  alcohol.  It  is  then  frozen 
with  ethyl  chloride  and  an  injection  of  one-third  of  a  grain  of  novocain 
or  cocain  in  1  to  2000  adrenalin  solution  is  made.  At  first  the  skin  is 
infiltrated,  then  a  few  drops  are  injected  into  the  intercostal  muscles, 
and  finally  into  the  pleura.  The  latter  must  not  be  neglected;  it 
appears  to  be  the  only  known  way  of  preventing  pleural  shock,  of 
which  we  shall  speak  later  on. 

Thoracocentesis. — The  patient  is  always  in  the  recumbent  position 
during  the  operation;  either  on  an  operating  table  or,  preferably,  in 
his  bed.  With  a  view  of  widening  the  intercostal  spaces,  the  hand  of 
the  side  to  be  operated  upon  is  placed  over  the  head.  The  selected 
intercostal  space  is  carefully  palpated  with  the  index  and  middle  fingers 
of  the  left  hand  to  make  sure  of  avoiding  a  rib  when  thrusting  the 
needle  into  the  chest  wall.  If  a  blunt  needle  is  used  the  skin  is  first 
punctured  with  a  tenotome.  The  needle  is  inserted  and  pushed  slowly 
forward,  passing  through  the  subcutaneous  tissue,  fascia,  and  muscles. 
While  the  latter  are  passed  the  needle  goes  smoothly  but  when  the 
endothoracic  fascia  is  reached  a  certain  amount  of  resistance  is 
encountered,  which  is  characteristic  to  the  experienced  hand.  Often 
a  snapping  sound  is  audible.  A  similar,  but  stronger,  resistance  is  felt 
when  the  pleura  is  passed  and  it  is  often  difficult  to  decide  with  confi- 
dence as  to  whether  it  was  the  fascia  or  pleura  which  was  punctured. 
"  Never  move  the  needle  sidewise,  for  if  it  should  be  in  the  lung  the 
latter  may  be  easily  torn  by  it"  (Balboni).  The  manometer  is  the 
only  means  at  our  command  to  make  sure  of  where  the  lumen  of 
the  needle  is. 
37 


578      OPERATIVE   TREATMENT— ARTIFICIAL   PNEUMOTHORAX 

How  far  the  needle  is  to  be  pushed  depends  on  the  thickness  of  the 
chest  wall  of  the  given  patient.  All  efforts  are  to  be  made  to  avoid 
penetrating  the  lung.  While  in  the  vast  majority  of  cases  this  is 
entirely  harmless,  on  rare  occasions  it  may  prove  a  serious  and  even 
a  fatal  accident.  We  may  induce  a  spontaneous  pneumothorax,  an 
accident  which  occurs  more  often  that  is  generally  appreciated. 

The  usual  length  of  the  needle,  Floyd's  modification  of  Brauer's, 
is  5  to  6  cm.  This  is  excessive  and  Saugman's  needle,  which  is  only  3 
cm.  long,  is  at  present  used  by  me  exclusively.  Saugman  noted  in 
100  cases  in  which  he  succeeded  in  inducing  pneumothorax  the  depth 
to  which  it  was  necessary  to  penetrate  the  chest  wall  as  far  as  the 
pleura;  and  in  none  of  them  was  it  deeper  than  3  cm.;  in  the  vast 
majority  it  was  only  between  1.5  and  2.5  cm.;  in  some  less  than  1.5 
and  in  one  even  less  than  1  cm. 

Technic  of  Insuflflation. — As  soon  as  the  lumen  of  the  needle  penetrates 
the  costal  pleura  and  there  are  no  adhesions  at  the  point  of  penetration, 
the  tube  leading  to  the  manometer  is  opened  and  the  fluid  in  the  closed 
limb  is  seen  to  be  sucked  up.  In  some  cases  the  suction  is  so  pro- 
nounced that  the  fluid  shoots  up  to  the  upper  end  of  the  tube  and  care 
must  be  taken  that  it  is  not  aspirated  into  the  pleura.  Usually  it  is 
elevated  between  1  and  6  cm.  and  oscillates.  The  patient  is  told  to 
take  a  deep  breath  and  it  will  be  observed  that  during  inspiration  the 
negative  pressure  is  more  pronounced  than  during  expiration.  This 
oscillation  is  the  only  reliable  indication  that  the  lumen  of  the  needle 
is  in  the  pleural  cavity,  but  at  times  there  are  observed  slight  oscilla- 
tions when  the  needle  reaches  the  costal  pleura  before  puncturing  it 
owing  to  the  respiratory  movements  of  the  lung.  But  these  oscilla- 
tions rarely  exceed  1  cm.  and  must  not  mislead  us.  Only  when  the 
negative  pressure  exceeds  3  cm.  may  we  venture  to  let  in  the  gas,  and 
beginners  should  not  do  it  with  less  than  5  or  6  cm.  negative  pressure. 

Manometric  Hints. — The  manometer  is  to  be  watched,  especially 
during  the  first  operation.  The  following  rules,  based  on  the  writings 
of  Forlanini,  Brauer,  Saugman,  Piery,  Balboni,  Frederick  C.  Coley,^ 
and  personal  experience,  are  useful  guides. 

Whetj  the  Lumen  of  the  XeecUe  is  in  the  Thoracic  Weill. — As  long  as 
it  is  outside  of  the  endothoracic  fascia,  the  manometer  rests  at  zero. 
When  it  reaches  the  endothoracic  fascia,  feeble  oscillations,  due  to 
respiratory  movements  of  the  pleura,  may  be  seen,  but  they  are  of 
slight  amplitude,  between  0  and  3  on  each  side  of  the  manometer. 
They  should  not  mislead  us  into  the  belief  that  the  lumen  is  in  the 
pleural  cavity.    The  fact  that  there  is  no  negative  pressure  proves  this. 

A  slight  negative  pressure  during  inspiration,  becoming  less  on  expi- 
ration, may  be  produced  when  the  point  of  the  needle  is  really  not  in 
the  pleural  cavity  at  all,  but  pushing  the  parietal  pleura  before  it. 
The  indications  are  clear — the  needle  is  to  be  pushed  ahead  guardedly 
till  it  punctures  the  parietal  pleura. 

»  Lancet,  1915,  ii,  469. 


TECHNIC  579 

After  the  Needle  Passed  the  Parietal  P/ewra.— When  there  are  no 
adhesions  there  is  at  once  seen  negative  pressure,  5  to  10  cm.,  and 
distinct  respiratory  oscillations,  higher  on  the  side  of  the  manometer 
which  is  connected  with  the  needle  than  on  the  side  communicating 
with  the  outer  air.  If  the  patient  holds  his  breath  during  inspiration 
or  expiration,  or  the  injection  is  stopped,  the  pressure  remains  negative 
or  positive  respectively. 

But  at  times  we  meet  with  this  anomalous  condition:  On  passing 
the  parietal  pleura  the  fluid  in  the  manometer  rises  high  showing  nega- 
tive pressure  of  10  cm.  or  more,  but  then  it  remains  stationary.  We 
know  then  that  the  lumen  is  in  the  pleural  cavity,  and  that  there  are 
no  adhesions,  but  we  hesitate  to  proceed  with  the  injection  because 
there  are  no  oscillations.  It  is  clear  that  the  lumen  of  the  needle  was 
for  a  moment  between  the  pleural  surfaces,  but  it  has  either  pushed 
the  visceral  pleura  ahead  of  it  or  entered  the  lung,  or  it  has  become 
clogged.  In  the  form.er  case  slight  withdrawal  of  the  needle  will 
reestablish  oscillations;  in  the  latter  case  we  put  the  obturator  into 
the  lumen  of  the  needle  and  clear  it. 

In  case  there  are  dense  adhesions  and  the  needle  does  not  enter  the 
pleural  cavity,  the  manometer  stays  at  zero  and  does  not  oscillate;  or 
when  slight  oscillations  are  noted  they  are  but  one  or  two  cm.  and 
equal  on  both  sides,  or  slightly  positive. 

When  there  are  slight  and  yielding  adhesions,  there  is  feeble  negative 
pressure,  about  2  to  3  cm.,  and  slight  oscillations.  Occasionally  the 
adhesions  yield  and  the  negative  pressure,  as  well  as  the  oscillations, 
suddenly  increases.  But  usually  the  pressure  becomes  positive  soon 
after  the  introduction  of  some  gas,  indicating  that  a  gas  pocket  has  been 
created.  During  reinflations,  sudden  drops  in  the  pressure,  due  to 
breaking  up  of  adhesions,  are  more  common  than  during  primary 
inflations. 

When  the  Lumen  of  the  Needle  is  in  the  Lung. — The  manometric 
indications  will  difi'er  according  to  the  structures  the  needle  has 
penetrated.  If  it  is  in  consolidated  lung  tissue  there  will  be  no  change 
in  the  level  of  the  fluid  in  the  manometer;  it  rests  at  zero.  If  the  lumen 
is  in  a  bronchus  or  bronchiole,  there  is  usually  no  negative  pressure, 
but  there  may  be  slight  oscillations  of  equal  excursions.  The  amplitude 
of  the  oscillations  will  depend  upon  the  character  of  the  respiration, 
whether  tranquil  or  labored.  When  the  patient  speaks,  the  respiratory 
eft'ort  with  a  closed  glottis  produces,  while  it  continues,  a  greatly 
increased  pressure,  greater  still  on  coughing.  When  the  patient  holds 
his  breath,  in  inspiration  or  expiration,  the  manometric  readings  are 
again  zero. 

If  while  inserting  the  needle  during  the  first  attempt  at  inflation 
positive  pressure  is  noted  during  expiration,  it  is  proof  that  the  lumen 
is  in  the  lung,  or  in  a  bloodvessel.  Occasionally  it  is  found  that  the  gas 
flows  in  freely,  but  the  pressure  in  the  manometer  does  not  ascend. 
This  is  an  indication  that  gas  is  escaping  as  it  enters  which  could  only 


580      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

occur  when  the  needle  is  in  a  bronchus  and  never  when  it  is  in  the 
pleura.  "If  the  key  connecting  with  the  nitrogen  is  quickly  opened 
and  immediately  closed,  allowing  only  a  very  minute  quantity  of 
nitrogen  to  flow  in,  the  manometer  then  becomes  positive,  it  is 
because  the  needle  is  in  the  lung"  (Balboni). 

If  the  lumen  of  the  needle  is  in  a  bloodvessel  there  are  no  oscillations, 
but  slight  positive  pressure  may  be  observed;  if  some  blood  enters 
the  needle,  which  is  the  rule,  the  pressure  will  be  rising.  When  with- 
drawing the  needle  it  will  be  found  that  it  contains  blood,  and  the 
patient  may  have  hemoptysis. 

Injection  of  the  Gas. — ^With  the  assurance  that  the  needle  is  in  the 
pleural  cavity  the  tube  leading  to  the  manometer  is  closed,  the  tube 
leading  to  the  gas  reservoir  is  opened,  and  nitrogen  allowed  to  flo"\^ 
in  by  aspiration,  or  pressure  when  necessary.  After  100  c.c.  of  gas 
have  entered,  the  manometer  is  again  consulted,  and  if  still  showing 
negative  pressure,  another  100  c.c.  is  allowed  to  flow  in.  It  has  been 
my  habit  never  to  exceed  300  c.c.  during  the  first  operation,  although 
many  do  not  hesitate  to  introduce  two  and  even  three  times  as  much, 
and  some  even  attempt  to  secure  complete  collapse  of  the  lung  during 
the  first  operation.  ]Murphy  advises  the  introduction  of  200  cubic 
inches  (3000  c.c.)  at  the  first  operation,  while  Foi'lanini  now  advises 
only  200  to  300  c.c.  Clinical  experience  seems  to  favor  smaller  quan- 
tities as  safer,  and  many  unpleasant,  often  dangerous,  symptoms  are 
thus  avoided.  To  change  quickly  the  relations  of  the  thoracic  viscera 
is  dangerous.  Moreover,  when  adhesions  are  present,  they  may  be 
forcibly  torn  apart  and  cause  trouble.  When  extensive  and  dense 
adhesions  are  present,  it  is  often  impossible  to  introduce  more  than 
100  to  200  c.c.  of  gas,  and  the  chances  of  finally  securing  a  complete 
collapse  of  the  lung  are  rather  slim. 

On  the  completion  of  the  operation  the  needle  is  quickly  withdrawn 
and  the  index-finger  of  the  left  hand  placed  over  the  point  of  the 
puncture  and  some  pressure  applied  with  a  view  of  preventing  cuta- 
neous emphysema.  Finally  the  small  wound  is  sealed  with  some  cotton 
and  collodion  and  the  patient  is  warned  against  coughing,  which  he  is 
to  avoid  as  far  as  is  within  his  control.  I  find  a  dose  of  morphin  or 
codein  is  useful  for  this  purpose.  It  has  been  my  rule  to  send  the 
patient  to  bed  for  twenty-four  hours  after  the  first  operation,  irre- 
spective of  his  general  condition. 

Method  in  Urgent  Cases. — In  urgent  cases,  as  in  copious  and  uncon- 
trollable pulmonary  hemorrhages,  and  when  no  apparatus  and  tank  of 
nitrogen  are  at  hand,  we  may  resort  to  Murphy's  method  which  he 
describes  as  exceedingly  simple:  "Take  an  ordinary  hypodermic  needle, 
rub  the  sharp  point  dull  on  a  brick,  cover  the  butt  end  of  the  needle 
with  cotton,  which  will  serve  as  a  filter  of  the  air  that  is  to  enter, 
then  insert  the  needle  into  the  pleura  at  the  ])oint  of  election  for  the 
production  of  a  ])neumothorax.  The  skin  should  haAc  been  painted 
with  iodin  and  punctured  with  a  tenotome.    The  idea  is  to  let  the  air 


TECHNIC  581 

enter  the  pleural  cavity  through  a  needle,  the  cotton  filtering  it  as  it 
enters,  thus  producing  a  pneumothorax.  The  finger  placed  over  the 
but  end  of  the  needle  serves  as  a  valve.  As  the  patient  inspires  the 
finger  is  lifted  oft'  the  needle  to  allow  the  air  to  enter,  and  on  expiration 
the  opening  is  closed  with  the  finger.  In  that  manner  you  can  pump 
the  pleural  cavity  full  of  air  to  any  desired  degree  of  compression.  If 
the  patient  becomes  too  cyanotic,  or  if  the  breathing  is  embarrassed,  lift 
the  finger  from  the  needle  and  allow  a  little  air  to  escape.  The 
procedure  is  now  reversed.  Close  the  end  with  the  finger  on  inspira- 
tion and  remove  the  finger  on  expiration,  so  that  air  will  be  pumped 
out  instead  of  in." 

Technic  of  Refilling. — The  introduction  of  a  few  hundred  cubic  centi- 
meters of  nitrogen  does  not  collapse  or  immobilize  the  lung.  This 
must  be  accomplished  gradually  by  further  inflations.  In  cases  with 
free  pleuree  this  is  a  simple  matter  considering  that  a  pocket  with  gas 
has  been  already  created  and  the  needle  can  be  easily  introduced  into 
it.  For  this  reason  it  is  best  to  do  the  second  inflation  in  the  neigh- 
borhood where  the  first  puncture  was  successfully  made,  so  that  it 
enters  the  gas  pocket,  and  only  exceptionally  is  another  place  chosen. 
In  the  latter  case  we  are  guided  by  the  same  principles  as  during  the 
primary  puncture. 

One  thing  is  to  be  remembered:  The  manometer  is  always  to  be 
consulted  before  the  gas  reservoir  is  opened  and,  in  case  no  respiratory 
oscillations  are  seen,  the  stillete  is  to  be  inserted  into  the  needle  on  the 
assumption  that  the  lumen  may  be  clogged,  which  is  often  the  case. 
If  no  oscillations  are  even  then  observed,  the  needle  is  to  be  withdrawn 
and  reinserted  in  another  place.  Accidents  have  happened  during 
later  inflations  just  as  during  primary  operations. 

The  quantity  of  nitrogen  introduced  diiring  refills  depends  on  the 
case.  My  way  has  been  to  introduce  between  300  and  600  c.c.  at  the 
second  and  800  to  1200  at  the  third  operation,  provided  the  patient 
bears  it  well.  But  when  I  find  embarrassment  of  the  circulation, 
dyspnea,  or  pain  in  the  chest,  I  proceed  slower  and  am  satisfied  with 
300  c.c.  given  every  other  day  till  complete  collapse  is  attained  in  two 
or  three  weeks.  We  are  also  to  be  guided  by  the  final  pressure  after 
each  inflation.  In  many  cases  we  get  positive  pressure  after  several 
hundred  cubic  centimeters  of  nitrogen  have  been  introduced,  although 
there  is  no  complete  collapse  of  the  lung.  We  often  meet  with  cases 
in  which  the  gas  opens  but  a  small  pocket  in  the  pleura  and  when  this 
is  filled  the  negative  pressure  decreases  or  vanishes.  When  oscillations 
are  good  the  pressure  may  be  increased  guardedly,  consulting  the 
manometer  after  each  50  or  100  c.c.  have  entered.  Saugman,  whose 
experience  is  unexcelled,  found  that  if  the  gas  does  not  pass  with  10 
to  15  cm.  water  pressure  the  case  may  be  given  up,  because  higher 
pressure  will  meet  with  failure. 

At  times  it  is  noted  that  during  a  refill  the  pressure  suddenly  sinks. 
This  is  an  indication  that  some  adhesions  have  yielded  or,  which  is 


582      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

fortunately  exceedingl}^  rare,  that  the  lung  has  ruptured  and  the  gas 
escapes  from  the  pleura  into  a  bronchus.  This  may  occur  when  the 
nitrogen  is  introduced  under  high  pressure  and  the  patient  coughs 
vigorously. 

My  experience  coincides  with  that  of  Saugman  to  the  effect  that  it 
is  best  that,  during  the  first  few  fillings,  the  final  pressure  should  not 
exceed  0.5  to  2  or  4  cm.  of  positive  manometric  pressure.  The  condi- 
tion of  the  patient,  as  well  as  his  reaction  during  the  succeeding  few 
days  should,  however,  be  our  guide.  We  must  always  watch  whether 
our  aim  is  not  attained  with  a  low  pressure,  and  in  many  cases  0.5 
to  1  cm.  above  zero  is  sufficient.  Forcible  inflations  involve  rapid 
dislocation  of  the  mediastinum  and  injury  to  the  other  lung.  We  must 
bear  in  mind  that  it  is  not  always  imperative  to  compress  the  lung. 
In  most  cases  affording  rest  to  that  organ  by  immobilization  is  sufficient 
to  give  relief,  and  this  can  be  attained  without  high  intrapleural  press- 
ure. But  in  case  the  patient  is  not  improving,  his  cough,  temperature, 
expectoration,  etc.,  are  not  influenced  favorably,  the  pressure  is  care- 
fully and  guardedly  increased.  A  final  pressure  of  10  to  15  cm.  of 
water  is  too  high,  though  many  authors  state  that  they  have  resorted 
to  it  in  some  cases.  Of  course,  as  a  rule,  the  gas  is  quickly  absorbed 
and  within  a  few  days  the  pressure  drops  so  that  the  embarrassment 
of  the  respiration  and  circulation  is  ameliorated.  The  great  problem 
is  the  cases  in  which  only  an  incomplete  pneumothorax  has  been 
created  and  the  stiff,  unyielding  walls  of  cavities,  or  dense  pleural 
adhesions,  prevent  the  compression  of  the  part  of  the  lung  which  we 
aim  to  collapse.  Saugman  and  Forlanini  have  not  hesitated  to  increase 
the  pressure  in  these  cases  to  30  and  even  40  cm.,  and  they  were 
occasionally  rewarded  by  finally  attaining  a  complete  pneumothorax. 

Frequency  of  Refilling. — ^After  complete  collapse  of  the  lung  has 
taken  place  the  frequency  of  the  refillings  is  diminished.  In  some 
patients  the  gas  is  absorbed  slower  than  in  others  and  we  are  unable 
to  say  in  advance  who  is  likely  to  need  frequent  refills  and  who  is  likely 
to  need  infrequent  refills.  It  seems  that  those  walking  around  absorb 
the  gas  sooner  than  those  who  remain  in  bed.  Primarily  the  guides 
for  the  necessity  for  refills  are  the  general  condition  of  the  patient 
and  secondarily  the  findings  on  physical  examination.  An  elevation 
of  temperature,  if  not  due  to  an  impending  or  actual  pleural  effusion, 
is  often  removed  by  a  refill.  The  same  is  true  of  cough  and  expectora- 
tion. In  those  who  had  the  lung  completely  collapsed,  there  is  a  com- 
plete absence  of  breath  sounds  and  adventitious  sounds ;  a  return  of 
these  is  an  indication  that  refilling  is  necessary.  The  fluoroscope  is, 
however,  the  best  guide.  But  I  want  to  repeat  that  dyspnea  and 
tachycardia,  which  are  often  caused  by  excessive  pressure  in  the  pleural 
cavity,  are  to  be  guarded  against. 

Symptoms. — The  acute  and  urgent  symptoms  of  spontaneous 
pneumothorax  are  never  seen  in  the  artificially  created  pneumothorax, 
excepting,  of  course,  when  the  lung  is  penetrated  and  the  sjiontaneous 


SYMPTOMS 


583 


variety  complicates  matters.  The  pain,  dyspnea,  cyanosis  and  col- 
lapse are  never  encountered.  In  fact  the  majority  of  patients  who 
have  overcome  the  fear  for  the  operation  are  ready  and  well  able  to 
leave  their  beds  immediately  after  the  operation  and  attend  to  their 
affairs.  The  slight  difficulty  in  breathing,  seen  in  some  cases  at  that 
time,  is  usually  objective,  the  patient  protesting  that  he  feels  well 
although  he  evidently  suffers  from  air  hunger  of  some  degree.     But 


September,  1914 


10     11     12      13     14     U     IG     1.     IS     19     aO     -21     -IJ 


85858585H585858585858585858585S58585858  58  5 


Fig.  87. — Showing  the  infl.uence  of  therapeutic  pneumothorax  on  the  temperature. 

even  this  disappears  within  a  couple  of  days,  as  has  already  been  men- 
tioned. Only  in  rare  instances,  when"  the  gas  separates  adhesions  by 
high  pressure,  does  the  patient  complain  of  pains  in  the  chest  which 
are,  as  a  rule,  trifling. 


October,  1914 


9  10  11  la  13  14  15  IG  U   18  19  20  31  Bj 


24  23  26  37   38  39 


Fig.  88. — Showing  the  influence  of  therapeutic  pneumothorax  on  the  temperature. 

In  febrile  patients  the  effects  of  the  pneumothorax  are  usually  strik- 
ing, especially  when  complete  collapse  of  the  lung  is  attained.  The 
fever  disappears  and,  in  successful  cases,  does  not  return  unless  there 
is  some  complication.  The  temperature  charts  (Fig.  87)  distinctly 
show  the  effects  of  collapse  on  the  temperature.  In  some  cases  it  is 
noted  that  the  fever  increases  1°  to  3°  F.  for  twenty-four  hours  after 
each  insufflation  (Fig.  88)  just  as  is  the  case  with  the  reaction  after 


584      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

an  injection  of  tuberculin.  This  is  probably  caused  by  increased  toxic 
absorption,  owing  to  the  compression  of  the  diseased  lung.  In  case 
an  increase  in  the  temperature,  lasting  several  days,  is  noted  during 
the  treatment,  we  may  look  for  some  unpleasant  complications,  espe- 
cially a  pleural  effusion.  When  the  pneumothorax  does  not  reduce 
the  temperature,  we  may  consider  the  treatment  a  failure  in  this 
particular  case.  With  the  disappearance  of  the  fever,  the  nightsweats 
vanish  and  this  gives  the  patient  great  relief. 

The  appetite  improves  in  successful  cases,  and  with  this  the  lost 
strength  is  gradually  regained,  and  the  languor,  which  is  such  a  strong 
clinical  feature  of  the  disease,  is  replaced  by  a  feeling  of  well-being. 

It  is  noteworthy  that,  in  spite  of  the  improvement  in  the  general 
condition  of  the  patients,  the  gain  in  weight  is  not  a  constant  phenom- 
enon in  artificial  pneumothorax.  As  long  as  the  general  condition  of 
the  patient  is  good,  and  the  loss  in  weight  inconsiderable,  it  should  not 
trouble  us.  -When,  however,  the  loss  of  weight  is  considerable  and 
general  symptoms,  such  as  fever,  sweats,  anorexia,  etc.,  make  their 
appearance,  we  may  first  try  to  reduce  the  pressure  in  the  thorax,  and 
if  this  does  not  ameliorate  the  condition,  the  treatment  may  have  to 
be  given  up. 

Great  relief  is  usually  obtained  in  patients  who  suffer  from  severe 
coughing  spells  which  keep  them  awake  during  the  night.  This  is 
especially  true  of  unilateral  cases  in  which  a  large  cavity  is  emptied 
by  compression.  After  the  first  three  or  four  inflations  it  is  constantly 
observed  that  the  amount  of  sputum  expectorated  is  augmented 
because  the  pressure  exerted  by  the  gas  empties  cavities  and  bronchi 
of  their  contents.  After  the  lung  has  completely  collapsed,  or  the 
cavities  have  been  emptied  in  partial  pneumothorax,  the  quantity  of 
sputum  diminishes,  and  in  unilateral  cases,  expectoration  ceases 
altogether.  In  many  cases  tubercle  bacilli  are  not  found  in  the  sputum 
after  the  lung  has  been  compressed  for  two  months. 

More  striking  than  the  improvement  in  the  general  condition  is  the 
cessation  of  hemoptysis  when  ths  first  inflation  is  made  in  a  case  of 
hemorrhagic  phthisis  in  which  the  patient  is  in  constant  dread  lest  the 
hemoptysis  recur.  We  can  assure  him  that  he  is  safe  in  this  regard. 
In  hemoptysis  pneumothorax  acts  as  a  hemostatic  like  the  tampon  in 
uterine  hemorrhage.  If  during  the  treatment  blood-spitting  occurs, 
despite  the  collapse  of  the  lung,  we  may  be  satisfied  that  the  blood 
comes  from  the  untreated  lung. 

In  many,  though  not  in  all  cases,  there  occurs  some  dyspnea  during 
the  operation  or  immediately  after.  But  this  is,  as  a  rule,  transitory. 
In  fact,  when  the  dyspnea  is  due  to  fever  or  toxemia  it  disappears 
after  the  induction  of  pneumothorax.  If  excessive  pressure  is  per- 
mitted to  prevail  in  the  treated  pleura,  dyspnea  is  likely  to  occur  which 
is  usually  transitory.  The  absence  of  the  dyspnea,  despite  the  cutting 
of  the  breathing  area  in  nearly  one-half,  is  not  sm-prising  because, 
in  pneumothorax  and  in  pleural  effusion,  a  reduction  of  66  per  cent. 


^  COMPLICATIONS  585 

of  the  respiratory  area  does  not  materially  alter  pulmonary  ventila- 
tion, nor  the  chemistry  of  respiration,  provided  the  patient  is  at  rest. 

Physical  Signs. — Recalling  the  physical  diagnosis  of  spontaneous 
pneumothorax  as  given  in  text-books,  we  are  surprised  that  most  cases 
of  artificial  pneumothorax  do  not  show  any  of  the  supposedly  pathog- 
nomonic signs.  Thus,  tympany  is  not  a  constant  sign,  and  in  some 
cases  the  treated  side  of  the  thorax  is  simply  hyperresonant  and,  in 
contrast  with  the  untreated  side,  only  shows  a  tympanitic  overtone, 
because  of  the  vicarious  emphysema  in  the  latter,  which  is  hyper- 
resonant or  even  tympanitic  on  percussion.  It  is  hazardous  to  diagnose 
pneumothorax  on  signs  obtained  by  percussion  alone.  The  only 
feature  that  may  give  a  clue  is  displacement  of  the  heart,  especially  in 
cases  of  left-sided  pneumothorax,  in  which  even  a  small  amount  of 
gas  may  shift  the  heart  to  the  right. 

On  auscultation  we  find  in  cases  with  complete  collapse  of  the  lung 
total  absence  of  breath  sounds,  as  well  as  of  any  rales  which  may  have 
been  audible  before  the  gas  was  introduced.  In  these  cases  we  may 
be  guided  by  the  auscultatory  findings  as  to  the  necessity  for  refilling. 
When  the  breath  sounds  return  it  means  that  quite  some  portion  of 
the  gas  has  been  absorbed  and  must  be  replaced  at  once.  In  cases  in 
which  the  lung  has  been  collapsed,  but  large  bronchi  have  remained 
active,  we  may  hear  distinct  and  exquisite  amphoric  breathing  or 
distinct  metallic  breath  sounds,  which  shows  that  the  teaching  of 
some  text-books  to  the  effect  that  the  amphoric  phenomena  in 
spontaneous  pneumothorax  are  invariably  due  to  bronchopleural 
fistulse  is  erroneous.  They  are  evidently  due  to  sounds  originating  in 
the  bronchi  which  reverberate  in  the  air  filled  pleural  cavity. 

The  progress  of  the  pneumothorax  can  usually  be  followed  by  noting 
the  increase  in  the  area  of  the  thoracic  surface  over  which  there  is 
either  absence  of  respiratory  sounds  or  amphoric  breathing  after  each 
filling,  till  finally  the  complete  lung  is  collapsed  and  all  breath  and 
adventitious  sounds  disappear. 

Complications. — Not  all  cases  of  induced  pneumothorax  run  a 
smooth  course  during  the  period  of  treatment.  Complications  may  arise 
during  the  operation  or  immediately  after,  and  while  the  patient  goes 
around  with  a  collapsed  lung.  Of  the  former,  collapse,  pleural  shock, 
or  pleural  eclampsia,  pains  in  the  chest,  and  subcutaneous  emphysema 
are  worthy  of  consideration;  of  the  latter  pleural  effusion  is  the  most 
important. 

Pleural  Shock. — Pleural  shock  may  be  of  various  degrees.  The  mild 
forms  manifest  merely  an  increase  in  the  rate  of  the  pulse  and  respira- 
tion, pallor,  dyspnea,  etc.,  which  pass  within  a  few  minutes  or  an 
hour.  I  have  met  with  it  several  times;  in  one  patient  it  occurred 
consecutively  during  the  first  four  inflations  and  I  am  inclined  to 
attribute  it  in  a  great  measure  to  his  fear  for  the  operation.  In  one 
of  my  cases  the  shock  was  quite  severe,  even  alarming,  yet  it  passed 
away  within  half  an  hour.    Several  authors  have  reported  fatal  cases. 


586      OPERATIVE   TREATMENT—ARTIFICIAL  PNEUMOTHORAX 

The  etiology,  especially  of  the  fatal  cases,  is  not  clear.  Forlanini, 
Saugman,  and  others  are  inclined  to  attribute  it  to  reflex  spasm  of  the 
cerebral  or  cardiac  bloodvessels.  It  has  been  observed  that  thoraco- 
centesis for  any  purpose  may  cause  collapse  or  even  death  on  very  rare 
occasions.  Brauer  is  inclined  to  attribute  the  symptoms  of  shock  to 
gas  embolism  in  most  cases  and  says  that  the  fact  that  it  is  usually 
transitory  does  not  exclude  gas  embolism.  But  pleural  shock  may 
occur  without  any  gas  inflations.  James  A.  Lyon^  mentions  a  case 
occurring  while  injecting  novocain  into  the  pleura. 

That  this  accident  is  comparatively  rare  is  evident  from  Forlanini's 
figures  to  the  effect  that  operating  on  134  patients,  not  including  those 
in  whom  he  failed  to  produce  a  pneumothorax,  and  making  more  than 
10,000  operations,  he  met  with  pleural  shock  only  twelve  times.  Among 
the  150  inflations  made  at  the  Montefiore  Home  we  observed  it  but 
once  to  be  sufficiently  severe  to  cause  some  alarm. 

Gas  Embolism. — When  the  manometer  is  not  properly  consulted, 
it  is  said  that  at  times  even  when  the  most  careful  technic  is  followed, 
gas  may  enter  a  bloodvessel  and  be  carried  away  to  any  part  of  the 
body  and  produce  an  embolism.  Usually  one  of  the  pulmonary  veins 
is  entered,  and  it  is  well  known  that  negative  pressure  prevails  in  these 
vessels.  Brauer  mamtains  that  one  of  the  veins  around  an  infil- 
trated area  of  lung  tissue  or  of  pleural  adhesions  may  be  penetrated  by 
the  needle  and  gas  introduced  into  the  circulation.  The  nitrogen  is 
carried  into  the  left  heart,  then  into  the  aorta,  whence  it  may  travel 
into  the  coronary  arteries  or  the  cerebral  vessels.  Experimental 
researches  have  not  been  uniformly  confirmatory  of  this  theory,  and 
clinically  the  symptoms  of  embolism  have  been  observed  in  some  cases 
even  when  no  nitrogen  was  allowed  to  enter  through  the  needle — 
merely  after  introducing  the  needle. 

Wolff-Eisner,-  while  agreeing  that  in  most  cases  it  is  due  to  gas 
embolism,  says  that  there  are  some  in  which  thrombi  are  responsible 
for  the  symptoms  observed.  They  are  derived  from  the  vessels  around 
or  within  the  pulmonary  or  pleural  lesion  and  dislodged  by  the  needle. 
However,  it  must  be  emphasized  that  symptoms  of  gas  embolism  are 
not  exclusively  encountered  in  the  primary  operations,  but  have 
been  met  with  during  refills. 

The  symptoms  are  collapse,  rapid  pulse,  irregularity  of  respiration, 
numbness,  giddiness,  inequality  of  the  pupils,  hemiplegia,  etc.  In 
some  rare  cases  death  has  occurred  without  warning.  I  have  been 
fortunate  in  not  liaving  met  with  a  single  case  of  this  kind  in  my 
practice.  Of  course  prophylaxis  is  to  be  the  chief  aim  while  operating, 
and  one  who  does  not  permit  the  gas  to  flow  into  the  chest  without 
considerable  oscillations  of  the  manometric  column  is  hardly  likely  to 
meet  with  a  case.  Fatal  cases  have,  however,  been  met  by  the  best 
and  most  experienced  operators. 

1  Boston  Med.  and  Surg.  Jour.,  1914,  clxxi,  329. 

2  Die  Progno.senstellung  bei  der  Lungentuberkulose,  Berlin,  1914,  p.  498. 


COMPLICATIONS  587 

Pains. — Pains  in  the  chest  are  felt  by  the  patient  occasionally  during 
the  operation.  At  times  while  introducing  the  needle  as  far  as  the 
costal  pleura  and  before  penetrating  it  exquisite  pains  are  felt  which 
promptly  disappear  as  soon  as  the  pleura  is  punctured.  This  can  be 
prevented  by  proper  anesthesia  of  the  pleura  with  novocain  or  cocain. 
Very  often  after  the  introduction  of  the  gas,  pains  are  felt  in  the  chest 
for  twenty-four  hours,  due  to  breaking  up  of  adhesions,  especially  when 
high  pressure  is  applied.  They  are  not  at  all  unbearable  and  need  no 
treatment.  Abdominal  pains  may  result  from  lowering  of  the  dia- 
phragm by  the  intrapleural  gas  pressure,  but  this  is  also  transitory  and 
needs  no  treatment. 

Spontaneous  Pneumothorax. — Spontaneous  pneumothorax  may  occur 
when  the  needle  lacerates  the  visceral  pleura,  or  when  a  superficial 
lesion  or  cavity  of  the  lung  breaks  through  after  the  pleural  sheets  are 
separated  by  the  gas.  Forlanini  has  met  with  9  cases  of  this  kind. 
Floyd^  and  Webb^  mention  it.  Alfred  Meyer^  mentions  a  case  in 
which  it  occurred  while  preparations  were  being  made  for  the  induction 
of  an  artificial  pneumothorax.  Of  course,  when  this  complication  is 
due  to  the  entry  of  the  needle  into  a  cavity,  or  even  a  caseating  part  of 
the  lung,  pyothorax  with  its  concomitants  are  likely  to  be  the  result. 
In  fact,  such  cases  have  been  reported. 

According  to  W.  Parry  Morgan,  "spontaneous"  pneumothorax  is 
more  often  produced  while  inducing  an  artificial  pneumothorax  than  is 
generally  appreciated.  This  is  confirmed  by  the  occasional  cases  met 
with  in  which  the  treatment  is  abandoned  after  a  futile  attempt  to 
introduce  gas  into  the  pleura,  and  a  collapsed  lung  is  then  discovered. 
Again,  a  radiogram  of  the  chest  taken  after  the  first  operation  usually 
shows  evidence  of  more  gas  in  the  pleural  cavity  than  has  been  hitro- 
duced  from  the  reservoir.  While  it  is  common  experience  of  those 
using  the  method  that  gas  can  be  detected  after  200  to  300  c.c.  have 
been  introduced,  it  has  been  Morgan's  experience  that  if  the  visceral 
pleura  is  not  injured  the  gas  cannot  be  detected  until  considerably 
more  than  300  or  400  c.c.  have  been  introduced.  He  concludes  that 
when  a  pneumothorax  is  visible  in  the  fluoroscope  after  introducing 
300  or  400  c.c.  of  nitrogen,  we  have  justification  for  the  conclusion  that 
radiographic  demonstration  of  a  pneumothorax  after  the  introduction 
of  such  a  quantity  of  gas  is  achieved  only  by  this  being  largely 
supplemented  by  leakage  from  the  lung. 

Emphysema. — The  infiltration  of  gas  into  the  subcutaneous  tissue 
of  the  thoracic  wall  around  the  point  of  puncture  is  very  frequently 
observed,  especially  in  those  operated  upon  by  the  Brauer  method. 
In  the  vast  majority  of  cases  it  is  due  to  the  high  pressure  of  the  gas 
in  the  pleural  cavity,  supplemented  by  cough,  and  the  nitrogen  works 
its  way  along  the  track  of  puncture.    It  is  readily  recognized  by  the 

1  Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  713. 

2  Trans.  National  Assn.  Study  and  Prev.  of  Tuberc,  1914,  x,  101. 

3  Ibid.,  p.  112. 


588      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

crepitation  elicited  on  palpation,  and  is  of  little  significance — passing 
away  spontaneously  within  three  or  four  days  or  at  most  a  week,  and 
further  inflations  are  not  contra-indicated  while  it  is  present.  It  may 
be  prevented  by  using  thin  needles  and  warning  the  patient  against 
coughing,  or  administering  some  sedative  like  codein  immediately 
after  the  operation.  It  has  occurred  in  about  one-half  of  my  cases 
after  the  first  or  second  operation  and  rarely  after  later  inflations. 

Of  more  serious  import  is  emphysema  of  the  deeper  tissues  of  the 
thorax  which,  fortunately,  occurs  only  rarely  and  may  be  avoided 
by  careful  technic.  It  is  usually  due  to  the  introduction  of  nitrogen 
into  the  subpleural  tissue  before  the  lumen  of  the  needle  has  pene- 
trated the  costal  pleura.  As  was  shown  by  Brauer,  Spengler,  and 
others,  deep  emphysema  may  also  be  due  to  leakage  from  the 
pleural  cavity  through  the  wound  made  by  the  needle,  the  gas 
being  pressed  by  the  intrapleural  pressure  or  the  respiratory  move- 
ments especially  during  cough,  into  the  extraplem'al  tissues.  Saug- 
man  is  of  the  opinion  that  this  may  even  occur  without  excessive 
intrapleural  pressure  although  the  latter  enhances  the  chances  of  its 
occurrence.  The  gas  works  its  way  along  the  path  of  the  vessels  to 
the  posterior  mediastinum  and  thence  along  the  vessels  and  trachea 
up  to  the  neck,  where  we  may  discover  it  by  the  crepitations  along 
its  anterior  aspect.  It  is  noteworthy  that  it  is  often  felt  earlier  on 
the  untreated  side  of  the  neck,  which  Saugman  believes  is  due  to 
posture.  Rarely  the  emphysema  may  extend  along  the  vessels  to  the 
face,  shoulder,  arm,  and  forearm.  It  may  be  severe  enough  to  cause 
dysphagia  and  pain  wherever  it  occurs.  But  the  ultimate  outcome  is 
always  favorable — it  disappears  within  a  few  days  or  a  week.  It 
has  occurred  in  two  of  my  cases  and,  barring  the  little  inconvenience 
it  caused  them,  it  was  of  no  significance.  Saugman,  who  had  con- 
siderable experience  with  deep  emphysema,  states  that  in  the  patients 
in  whom  it  occurs  there  are  but  few  chances  of  inducing  a  complete 
pneumothorax  because  of  the  gas  leakage. 

With  the  abdominal  emphysema  which  has  been  described  by  several 
authors,  I  have  had  no  experience.  It  may  occur  when  the  needle  is 
inserted  along  the  lower  margin  of  the  chest  and  the  diaphragm  happens 
to  be  unduly  high,  which  is  not  unusual  in  pulmonary  tuberculosis. 
The  lumen  of  the  needle  may  then  reach  the  peritoneum,  between  the 
diaphragm  and  the  stomach  or  liver.  It  is  to  be  remembered  that 
there  also  the  manometer  will  show  negative  pressure,  oscillating  with 
the  respiratory  movements.  Saugman  points  out  that  it  is  difficult 
to  distinguish  these  oscillations  from  those  seen  when  the  needle  is  in 
the  pleural  cavity,  but  if  it  is  carefully  watched  it  will  be  observed  that 
when  the  needle  is  in  the  pleural  cavity  the  negative  pressure  is  stronger 
during  inspiration,  and  the  reverse  is  true  when  the  lumen  of  the 
needle  is  in  the  peritoneal  cavity. 

Pleural  Effusions. — The  most  frequent  and  serious  complication  of 
artificial  pneumothorax  is  pleural  effusion  in  the  course  of  the  treat- 


COMPLICATIONS  ,  589 

ment.  Its  frequency  varies  with  the  different  reports  by  various 
authors.  Some  report  as  high  as  60  per  cent,  of  cases,  while  others 
have  met  with  it  less  frequently.  Some  are  inclined  to  attribute  it  to 
"colds''  or  to  "rheumatism,"  etiological  factors  which  are  open  to 
question.  Others  have  stated  that  it  is  usually  due  to  infection 
during  the  operation  and  maintain  that  when  asepsis  is  rigidly 
observed,  effusions  are  rare,  which  does  not  hold,  because  effusions 
have  been  met  by  the  most  careful  of  operators.  Floyd  says 
that  where  injections  are  very  frequent  and  small  amounts  of 
nitrogen  are  given  at  a  time  it  is  more  likely  to  occur  than  where  the 
uiterval  is  of  some  duration.  Bullock  and  Twitchell^  say  that  it  may 
be  prevented  by  using  warm  nitrogen.  Faginoli^  considers  the  nitrogen 
as  a  foreign  body  which  irritates  the  serous  sm-face  of  the  pleura, 
predisposing  it  to  disease.  It  becomes  a  locus  minoris  resisientioB,  and 
inflammation  occurs  more  easily  than  in  ordinary  cases  of  phthisis. 
Klemperer's^  explanation  is  more  plausible:  Disease  processes  which 
reach  the  surface  of  the  lung  and  the  visceral  pleura,  cause  adhesions 
in  patients  with  normally  superimposed  pleural  sheets,  but  in  pneu- 
mothorax with  separated  pleural  sheets  exudative  inflammations  are 
the  result.  Ruptures  of  adhesions  which  lay  bare  tubercular  foci  in 
the  pleura  may  also  be  instrumental  in  infecting  the  complete  serous 
surface.  Bullock  and  Twitchell^  consider  these  exudates  a  response  to 
irritation  by  the  foreign  body,  the  gas.  "The  secretion  of  a  fluid  by 
the  pleura  is  as  natural  a  phenomenon  as  that  of  tears  by  the  con- 
junctiva. If  the  tear  duct  is  occluded,  the  tears  will  overflow  upon  the 
cheeks.  When  the  mechanism  of  the  pleura  is  in  perfect  working 
order  as  to  secretion  and  absorption  an  excess  of  fluid  is  never  found; 
but  we  certainly  know  that  as  pneumothorax  is  protracted  the  absorp- 
tion properties  of  the  pleura  became  more  and  more  impaired."  The 
fact  that  the  fluid  usually  contains  lymphocytes  and  is  pathogenic  to 
animals  is  conclusive  proof  of  the  tuberculous  origin  of  these  effu- 
sions. 

The  diagnosis  is  difficult  at  the  onset.  In  most  cases  there  is  a  rise 
in  the  temperature,  though  at  times  it  may  pass  afebrile;  but  there  is 
no  chill.  The  fever  is  hectic  and  may  reach  103°  F.  and  higher.  There 
is  also  a  rise  in  the  intrapleural  pressure  which  cannot  be  accounted  for 
by  the  insufflations,  and  the  manometric  oscillations  are  diminished. 
Groco's  triangle  can  be  made  out  when  the  effusion  is  considerable, 
though  Faginoli  says  that  it  is  always  absent.  Small  effusions  are 
often  very  difficult  to  diagnosticate,  and  even  the  fluoroscope  may  fail 
to  reveal  them.  They  are  especially  difficult  to  discern  in  radio- 
grams which  have  been  taken  with  the  patient  reclining,  for  obvious 
reasons.   When  more  or  less  copious,  the  usual  signs  of  pleural  effusion 

1  Amer.  Jour.  Med.  Sci.,  1915,  cxlix,  848. 

2  Riv.  crit.  di  clin.  med.,  1912,  xiii,  678,  694. 
3Berl.  klin.  Wchnschr.,  1911,  cxlvii,  372. 

*  Amer.  Jour.  Med.  Sci.,  1915,  cxlix,  848. 


590      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

are  present  plus  the  succussion  sound  and  the  splash,  which  are  at 
times  annoying  to  the  patient. 

The  effects  of  the  eft'usion  depend  on  whether  they  are  of  a  toxic 
nature  or  not.  In  the  former  case  there  is  prolonged  fever  of  a  hectic 
type.  Simple  effusions,  as  has  been  pointed  out  by  von  Muralt,  are 
rather  salutary  phenomena  and  may  have  a  good  effect  on  the  gen- 
eral and  local  condition  of  the  patient  by  the  antibodies  they  produce. 
Faginoli  does  not  agree  with  this  view  and  says  that  in  the  end  effu- 
sions interfere  more  or  less  with  the  favorable  outcome  of  the  case. 
Saugman  also  states  that  in  the  majority  of  cases  it  is  a  rather  dis- 
agreeable complication,  which  is  in  agreement  with  my  experience. 
The  patients  who  have  had  effusions  have  not  done  as  well  as  those 
without  this  complication. 

As  long  as  there  is  no  fever  and  no  cardiac  embarrassment,  the 
effusion  should  not  be  interfered  with,  because  it  keeps  the  lung 
collapsed,  and  this  is  just  at  what  we  aim  with  the  treatment.  But  in 
cases  in  which  the  fever  is  high  it  may  be  necessary  to  withdraw  part 
of  the  fluid  and  replace  it  with  nitrogen.  In  some  cases  I  have  applied 
autoser other apy — withdrawing  10  c.c.  of  fluid  and  reinjecting  it  sub- 
cutaneously,  and  am  under  the  impression  that  it  enhances  absorption. 
We  must  always  watch  these  exudates.  In  case  they  are  absorbed  too 
rapidly,  the  lung  reexpands  and  may  form  adhesions,  thus  preventing 
its  further  collapse  by  the  gas  inflations.  Pyopneumothorax  is  not 
rare.    It  is  in^^ariably  fatal  sooner  or  later. 

Active  Lesions  in  the  Untreated  Side. — Extension  of  the  disease  in 
the  other  lung  is  perhaps  the  most  disheartening  complication  during 
the  treatment.  It  has  been  stated  that  it  may  be  caused  by  an  attempt 
to  collapse  the  more  affected  lung  too  quickly;  the  purulent  matter 
is  squeezed  out  rapidly,  and  it  travels  along  the  bronchi  to  the  other 
side  of  the  chest,  producing  pus  embolisms.  It  has  also  been  attributed 
to  excessive  pressure  in  the  pneumothorax.  It  has  occurred  in  some 
of  my  cases  and  in  none  could  I  attribute  it  to  these  causes.  In 
some  of  my  cases  there  was  a  hemorrhage  from  the  untreated  lung, 
but  it  soon  ceased.  There  have  been  reported  cases  in  which  one 
side  of  the  chest  was  treated  by  a  pneumothorax  and  the  lesion  was 
cured,  but  subsequently  a  new  lesion  flared  up  in  the  opposite  lung, 
which  was  also  treated  by  a  pneumothorax.  This  indicates  that  the 
collapse  and  compression  of  a  lung  do  not  necessarily  impair  its  function 
permanently. 

Indications. — Forlanini  at  first  urged  that  only  far  advanced  cases 
of  phthisis  for  which  everything  had  already  been  tried,  but  no  relief 
was  obtained,  should  be  given  artificial  pneumothorax.  xA.s  a  conditio 
sine  qua  non  it  was  insisted  upon  that  the  lesion  must  be  strictly 
unilateral,  and  that  any  involvement  of  the  other  side  of  the  chest 
is  a  contra-indication  to  the  treatment. 

Factors  Entering  into  the  Selection  of  Cases. —  The  Form  and  Staf/e 
of  the  Disease. — There  are  numerous  cases  of  phthisis  which  are  doing 


INDICATIONS  591 

well  and  even  recover  with  or  without  any  treatment,  medicinal, 
specific,  climatic,  or  institutional,  and  it  is,  of  course,  not  advisable 
to  subject  them  to  the  operation  with  its  potential  complications. 
This  is  true  of  mild  incipient  cases  and  abortive  tuberculosis.  Fibroid 
phthisis  runs  an  exceedingly  chronic  course;  the  pleura  is  often 
extensively  involved,  precluding  the  introduction  of  gas  into  the  hemi- 
thorax  most  affected  and  cannot  be  treated  by  this  method.  This  is 
also  true  of  the  most  common  forms  of  fibroid  phthisis  characterized 
by  diffuse  fibrosis  all  over  both  lungs,  and  it  would  be  sheer  folly  to 
treat  but  one  side  of  the  chest.  On  the  other  hand,  in  the  later  stages 
of  diffuse  fibrosis,  when  excavations  form  in  one  lung,  the  question  of 
pneumothorax  is  to  be  considered,  provided,  of  course,  that  the  pleura 
is  free  from  dense  and  extensive  adhesions. 

It  is  the  acute  and  progressive  form  of  phthisis  in  which  artificial 
pneumothorax  finds  its  best  indications  and  shows  the  best  and  most 
striking  therapeutic  results.  In  the  group  of  cases  known  as  galloping 
consumption,  in  which  the  patient  is  carried  off  within  three  to  six 
months  by  a  rapidly  progressing  infiltration,  caseation  and  excavation,, 
there  are  many  who  can  be  saved  by  the  induction  of  pneumothorax. 
It  is  fortunate  that  dense  pleural  adhesions  are  exceptional  in  these 
cases  and  a  pneumothorax  can  easily  be  induced.  The  results  are 
often  astonishing — with  the  collapse  of  the  lung,  the  tachycardia, 
fever,  nightsweats,  cough,  expectoration,  etc.,  disappear,  and  within 
a  few  weeks  the  patient  is  reinvigorated  and  may  continue  to  gain 
in  weight  and  strength  indefinitely. 

Another  group  of  cases  in  which  artificial  pneumothorax  renders 
excellent  service  are  those  which  have  recurrent,  copious,  and  uncon- 
trollable hemorrhages.  While,  when  afebrile,  the  patients  are  not  in 
grave  danger,  and  death  due  to  exsanguination  is  rare,  yet  our  efforts 
to  prevent  recurrence  of  hemorrhage  after  one  has  been  stopped  by 
keeping  the  patient  in  bed  for  several  weeks  are  often  futile,  and  he, 
as  well  as  those  around  him,  are  discouraged.  I  have  had  some  patients 
who  had  to  remain  in  bed  for  two  or  three  months  with  slight  but  pro- 
tracted hemorrhages,  one  following  another.  With  the  induction  of  a 
pneumothorax,  provided  we  succeed  in  completely  collapsing  the 
lung,  we  have  an  excellent  means  of  controlling  the  hemorrhage, 
to  prevent  its  recurrence,  and  in  addition  to  giving  the  tuberculous 
focus  an  opportunity  to  heal. 

It  is  obvious  that  only  one  lung  may  be  compressed  while  the 
second  must  be  left  to  carry  on  the  functions  of  respiration,  and  that 
it  is  useless  to  combat  a  lesion  in  one  lung  while  the  disease  is  smoulder- 
ing or  progressing  in  the  other.  For  these  reasons  it  has  been  found 
advisable  to  apply  pneumothorax  only  in  unilateral  cases.  But  as  a 
matter  of  fact,  in  more  or  less  advanced  phthisis  unilateral  lesions  are 
hardly,  if  ever,  met  with.  Klemperer  says  that  he  hardly  knows  of  a 
case  in  which  only  one  lung  was  extensively  involved  and  the  other 
remained  free  from  the  disease  in  the  anatomical  or  bacteriological 


592      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

sense.  Clinical  experience  is  supported  in  this  regard  by  autopsy 
findings.  Inasmuch  as  strictly  incipient  cases  are  not  to  be  treated 
by  this  method  for  reasons  already  stated,  it  is  evident  that  in  nearly 
all  cases  in  which  pneumothorax  is  indicated  there  will  be  found  signs 
of  involvement  of  both  lungs  and  we  must  be  satisfied  with  mild  or 
moderate  lesions  in  the  untreated  side. 

In  practice  we  find  that  in  the  vast  majority  of  moderately  and 
far-advanced  cases  the  lesions  are  extensive  and  active  in  one  lung, 
while  in  the  opposite  there  is  limited  involvement,  or  signs  of 
quiescent  or  healed  lesions.  Though  not  strictly  unilateral,  these  cases 
can  be  successfulh'  treated  by  pneumothorax,  if  not  prevented  by 
pleiu-al  adhesions. 

It  is  interesting  that  careful  clinical  and  pathological  observations 
have  shown  that  only  exceptionalh'  is  the  untreated  lung  unfavorably 
affected.  In  spite  of  the  increased  functional  activity  because  of  the 
vicarious  work  it  is  compelled  to  do,  the  lung  usually  remains  in  the 
same  condition  as  it  was  before  the  opposite  lung  was  collapsed.  The 
vicarious  emphysema  which  is,  as  a  rule,  produced,  increases  the  size 
and  dilates  the  alveoli  and  bronchioles,  thus  permitting  as  much  air 
to  be  passed  through  as  before,  when  both  lungs  were  active.  Forlanini, 
Saugman,  Robinson,  Floyd,  Hamman,  von  Adelung,  Lyon,  and  many 
others  have  reported  cases  in  which  active  lesions  in  the  untreated 
lung  have  improved  or  healed  after  a  pneumothorax  was  induced  in 
the  more  affected  side.  The  factors  operative  in  such  cases  are  not 
well  understood.  Carpi^  has  pointed  out  that  amphoric  sounds  and 
rales  are  often  altogether  transmitted  from  the  more  affected  side 
and  that  diagnosis  is  very  difficult.  On  the  other  hand,  the  increased 
blood  supply  may  have  something  to  do  with  it.  The  diminution  in 
toxic  absorption  from  the  ulcerating  and  excavated  lung  may  give  the 
patient  a  chance  to  recoup  his  natural  reparative  forces,  unliampered 
by  the  toxemia  from  extensive  suppurating  areas.  However,  this  is 
not  the  rule.  In  some,  lesions  in  the  untreated  lung  flare  up  and 
extend,  as  has  happened  in  some  of  my  cases.  In  some  of  my  cases 
copious  hemoptysis  even  occurred  from  the  untreated  lung. 

Recently  Forlanini  and  many  others  have  argued  that  all  advanced 
cases  should  be  given  an  opportunity  to  benefit  by  artificial  pneumo- 
thorax. In  far-advanced,  bilateral,  or  "hopeless"  cases  one  side  as  is 
a  rule  extensively  involved,  while  the  other  side  shows  only  limited 
involvement,  though  the  lesion  may  be  evidently  active.  In  such  cases 
it  is  urged  that  the  more  affected  side  should  be  treated  on  the  principle 
that  there  is  nothing  to  lose  and  everything  to  gain.  Forlanini's 
experience  has  taught  him  that  when  the  untreated  side  has  but  a 
limited,  even  though  active  focus,  the  chances  of  a  success  are  better 
than  would  be  expected  a  priori.  "When  both  sides  are  extensively 
affected  the  chances  of  recovery  are  slim  indeed,  but  improvement  in 

1  Gazz.  med.  ital.,  1911,  Ixii,  461,  473. 


INDICATIONS  593 

the  general  condition  may  be  anticipated  and  a  prolongation  of  life 
is  not  unlikely.  At  times,  Forlanini  says,  we  may  be  astonished  that 
even  such  patients  are  cured.  In  most  cases  the  removal  or  diminution 
of  toxic  absorption  gives  the  patient  an  opportunity  to  muster  his 
natural  forces  of  resistance  and  comfort,  often  superior  to  that 
obtained  in  operative  procedures  for  incurable  cancer  of  the  stomach 
may  be  procured. 

There  is  another  important  point  to  be  borne  in  mind :  We  are  not 
always  able  to  ascertain  positively  w^hether  the  lesion  in  the  less 
affected  side  is  active,  quiescent,  or  even  healed.  Rales  and  amphoric 
breath-sounds  heard  over  a  given  area  of  the  chest  wall  are  not  always 
autochtonous,  but  may  be  in  fact  transmitted  by  conduction  from 
the  opposite  side,  and  this  is  at  times  very  diflficult  to  differentiate, 
as  was  already  mentioned.  Indeed,  perfect  symmetry  of  location  of 
rales,  especially  on  both  sides  of  the  spine  in  the  upper  part  of  the 
chest  posteriorly  should  always  excite  suspicion  that  they  may  be 
transmitted,  and  on  the  side  on  which  they  are  weaker  it  is  probably 
so.  During  and  after  pulmonary  hemorrhages  also  there  are  often 
heard  rales  all  over  the  chest  which  disappear  in  the  unaffected  side 
within  several  days,  but  w^hen  audible  they  give  the  impression  that 
both  lungs  are  extensively  involved.  Skiagraphy  is  of  little,  if  any, 
assistance  in  clearing  up  many  of  these  cases. 

Some  French  and  Italian  authors  have  suggested  "diagnostic 
pneumothorax"  in  cases  in  which  we  are  uncertain  whether  the  disease 
is  active  in  both  sides.  The  more  affected  pleura  is  inflated  with  gas 
and  the  opposite  lung  is  watched.  In  cases  in  which  the  physical  signs 
of  disease  are  of  the  transmitted  kind,  they  disappear  soon  after  the 
lung  is"  collapsed.  But  in  case  they  persist  in  spite  of  a  complete 
pneumothorax  and  the  general  condition  of  the  patient  is  aggravated, 
the  pneumothorax  is  allowed  to  be  absorbed  or,  in  more  urgent  cases, 
the  gas  is  aspirated  and  the  lung  permitted  to  reexpand. 

There  are  some  who  believe  that  even  incipient  cases  ought  to 
be  treated  with  pneumothorax.  Among  these  may  be  mentioned 
Murphy,^  Lemke,  Bullock  and  Twitchell,  Gray,^  Forlanini,  von 
Adelung,  Piery,  and  some  others.  Murphy  and  Kreuscher  say:  "Is 
it  well  to  wait  until  the  outlook  is  so  desolate?  Is  the  lung  col- 
lapse such  a  desperate  operation  as  to  be  used  only  as  a  last  resort?" 
With  this  I  am  not  in  agreement.  If  the  treatment  lasted  only  a  cer- 
tain and  limited  time,  the  patient  could  be  informed  of  the  details 
and  given  the  choice.  But  inasmuch  as  we  are  not  in  a  position  to  give 
the  patient  definite  information  as  to  the  probable  duration  of  the 
treatment,  and  a  large  proportion  of  these  cases  recover  under  the  old 
and  tried  methods  of  treatment,  we  should  not  subject  mild  incipient 
cases  to  the  dangers,  complications,  and  duration  of  pneumothorax. 
I  still  hold  that  only  progressive  or  hopeless  cases  are  to  be  given  this 
treatment. 

1  Interstate  Med.  Jour.,  19U,  xxi,  266.  2  Illinois  Med.  Jour.,  1913,  xxiv,  201. 

38 


594      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

Contra-indications. — To  some  extent  the  contra-indications  have 
already  been  given  while  speaking  of  the  indications,  but  there  remain 
yet  to  be  discussed  certain  conditions  which  preclude  the  induction  of 
an  artificial  pneumothorax,  mainly  those  depending  on  the  clinical 
form  of  the  disease,  the  coexistence  of  extrathoracic  tuberculosis  and 
of  other  diseases.  Because  pneumothorax  only  acts  locally  on  the 
treated  lung,  acute  miliary  tuberculosis,  in  which  both  lungs  are 
usually  equally  involved,  is  not  suitable  for  this  treatment.  Fibroid 
phthisis  with  extensive  pulmonary  emphysema  is  not  suitable  for  this 
mode  of  treatment,  excepting  when  in  addition  to  the  emphysema 
there  is  a  localized  suppurating  excavation  which  is  the  cause  of  fever, 
sweats,  cough,  expectoration,  e.tc,  undermining  the  patient.  An 
artificial  pneumothorax  may  be  applied  as  a  palliative  measure. 

The  most  important  forms  of  extrathoracic  tuberculosis  which 
complicate  phthisis  are  laryngeal  and  intestinal  involvement.  Clinical 
experience  has  shown  that  pneumothorax  may  relieve  these  compli- 
cations to  an  amazing  extent.  It  appears  that  when  the  tuberculous 
toxemia,  due  to  an  extensive  focus  in  the  lung,  is  removed  by  a 
pneumothorax,  the  laryngeal  and  intestinal  lesions  often  improve  and 
there  are  even  some  cases  in  which  complete  cure  was  obtained  of 
both  the  lung  condition  and  the  extrathoracic  lesions.  A.  de  Gradi,^ 
Zink,^  von  Adelung,  and  others  have  reported  such  cases,  and  Forlanini 
speaks  of  them,  though  he  confesses  his  inability  to  explain  them. 
Conceding  that  the  chances  of  cure  are  remote,  laryngeal  and  intestinal 
complications  should  not  deter  us  from  applying  pneumothorax  if  the 
case  is  otherwise  suitable,  on  the  principle  that  there  is  nothing  to  lose 
and  everything  to  gain. 

Diseases  of  the  heart,  bloodvessels,  and  kidneys  have  been  found  to 
materially  lessen  the  chances  of  recovery  with  an  artificial  pneumo- 
thorax and  are  therefore  mentioned  as  contra-indications  to  the  treat- 
ment. They  are  all  accompanied  by  disturbances  of  the  circulation 
and  the  patients  do  not  bear  the  deprivation  of  the  breathing  area  of 
a  complete  lung.  Forlanini,  however,  has  found  that  when  compen- 
sation is  good,  pneumothorax  may  be  induced  with  same  chances  of 
success.  Some  object  to  the  production  of  a  pneumothorax  in  persons 
over  forty  years  of  age. 

Diabetes  has  not  been  found  to  interfere  with  the  successful  out- 
come of  an  artificial  pneumothorax,  and  the  same  is  true  of  preg- 
nancy. There  have  been  reported  several  cases  in  which  pneumothorax 
was  induced  in  pregnant  women  who  went  on  to  term,  were  deli^'ered 
of  healthy  infants,  and  continued  under  the  treatment.  In  one  of  my 
cases  the  woman  was  six  months  pregnant  when  a  pneumothorax  Avas 
induced.  The  effect  on  the  lung  was  excellent,  complete  collapse 
was  attained  and  the  general  symptoms  completely  disappeared. 
The  temperature  chart  (Fig.  89)  shows  clearly  the  effect  on  the  fever 

1  Gazz.  med.  ital.,  1910,  Ixi,  281. 

2  Bcitr.  z.  Klinik  d.  Tuberkulosc,  1913,  xxvii,  155. 


CONTRA-INDICA  TIONS 


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596      OPERATIVE   TREATMENT— ARTIFICIAL  PNEUMOTHORAX 

which  has  been  so  far  permanent  for  two  years.  But  she  miscarried 
four  weeks  after  the  first  inflation  of  gas.  It  is  noteworthy  that  the 
temperature  and  the  general  condition  of  the  patient  were  not 
influenced  by  the  miscarriage. 

Pleural  Adhesions. — These  are,  strictly  speaking,  not  necessarily 
contra-indications  to  the  induction  of  a  pneumothorax,  but  they  are 
hindrances  to  its  successful  accomplishment.  In  many  cases  no  nitro- 
gen at  all  can  be  introduced  because  of  extensive  and  dense  adhesions 
and,  after  several  punctm-es  are  made,  the  case  is  given  up  as  unsuit- 
able for  treatment.  Frequently  an  area  is  found  which  is  free  and 
some  gas  is  introduced,  but  further  attempts  to  introduce  a  sufficient 
quantity  to  completely  collapse  the  lung  meet  with  failure.  This 
failure  may  be  of  various  degrees.  In  some  the  pleura  is  free  only 
over  a  small  area  and  a  small  pocket  of  gas  can  be  made,  while  the  rest 
of  the  pleura  is  adherent.  No  improvement  in  the  condition  can  be 
expected  and  the  treatment  must  be  abandoned.  Pleural  adhesions 
often  interfere  wdth  the  treatment  in  a  peculiar  wa^^  The  pleura  is 
free  all  over  the  chest  except  its  upper  third,  over  the  tuberculous 
lesion,  where  it  is  densely  adherent.  There  may  be  a  cavity  in  that 
location  surrounded  by  stiff  walls.  The  result  is  that  while  we  succeed 
in  collapsing  the  lower  two-thirds  of  the  lung,  the  part  which  is  diseased 
and  which  we  aim  mainly  at  collapsing  in  order  to  expel  the  pus  and 
detritus  from  the  purulent  cavity  and  thus  prevent  toxic  absorption 
and  bring  about  coaptation  of  its  wall  with  a  view  of  giving  them  an 
opportunity  to  cicatrize,  cannot  be  collapsed  and  the  disease  keeps 
on  its  usual  course.  This  is  notably  the  case  with  old  cavities  having 
stiff  fibrous  walls  which  refuse  to  yield  to  the  gas  pressure.  Many 
failm-es  are  due  to  this  condition.  Fig.  3,  Plate  XVIII  shows  a  radio- 
gram of  such  a  case.  In  spite  of  all  efforts  to  collapse  the  lung 
completely,  the  adhesions  around  the  lesion  prevented  the  collapse 
of  the  diseased  part  of  the  lung. 

At  times  the  pleural  adhesions  are  not  very  dense,  in  fact  slight 
adhesions  are  said  to  be  present  in  practically  all  advanced  cases  of 
phthisis,  and  an  increase  in  the  pressure  while  introducing  the  gas 
breaks  them  up  and  success  is  finally  attained — ^the  lung  is  completely 
collapsed. 

The  proportion  of  cases  suitable  for  the  treatment  is  very  small 
indeed.  Among  210  patients  admitted  to  the  Montefiore  Home  we 
found  only  22  which  we  considered  suitable  for  the  treatment.  This 
is  a  rather  high  percentage  and  is  partly  due  to  the  fact  that  strong 
eft'orts  were  made  by  me  i:o  find  suitable  patients  outside  of  the  insti- 
tution and  induce  them  to  enter.  Statistics  of  most  writers  seem  to 
indicate  that  less  than  5  per  cent,  of  all  cases  that  come  under  their 
observation  are  suitable  for  this  treatment.  Lemke^  appears  to  be  the 
only  author  whose  clinical  experience  has  been  to  the  eft'ect  that  he 
has  had  to  abandon  the  operation  in  all  but  a  small  proportion  of  the 

»  Jour.  Amer.  Med.  Assn.,  1S99,  xxx,  959,  1023,  1077. 


DURATION  OF  THE   TREATMENT  597 

selected  cases,  because  of  pleural  adhesions.  Perhaps  the  reason  is 
that  he  operated  on  incipient  cases.  Bernard^  found  among  628 
patients  only  22  in  whom  he  thought  pneumothorax  was  indicated, 
and  among  these  he  succeeded  only  in  G  cases  in  completely  collapsing 
the  lung,  in  11  adhesions  prevented  the  creation  of  a  complete  pneu- 
mothorax, and  3  refused  to  submit  to  the  treatment.  J.  Courmont 
found  among  352  patients  only  31  were  suitable.  Among  110  appar- 
ently suitable  cases  only  in  32  per  cent,  could  Zink  produce  complete 
pulmonary  collapse,  and  in  24  per  cent,  he  failed  to  enter  the  pleura 
altogether  because  of  pleural  adhesions. 

Saugman  found  that  in  30  per  cent,  of  the  selected  cases  adhesions 
prevented  the  entry  of  gas  into  the  pleural  cavity.  Even  with  Brauer's 
method,  the  proportion  of  failures  exceeds  25  per  cent.  It  must,  how- 
ever, be  mentioned  here  that  while  in  most  cases  complete  collapse  is 
best,  a  partial  pneumothorax  at  times  serves  a  good  purpose,  and 
many  writers  report  excellent  results  when  only  creating  one  or  more 
gas  pockets  in  the  pleura,  and  in  two  of  my  cases  the  improvement 
was  remarkable  under  such  conditions.  Von  Adelung  even  practises 
partial  inflation  of  the  two  pleurae  simultaneously  in  bilateral  cases, 
and  he  says  that  the  results  have  thus  far  been  apparently  beneficial. 
To  my  mind  this  improvement  can  only  be  seen  in  chronic  cases  of 
phthisis  in  which  the  cavities  have  been  surrounded  by  stiff  walls 
of  connective  tissue,  and  which  do  not  secrete  any  more.  Exquisite 
amphoric  breath  sounds  are  heard  over  such  cavities,  but  no  rales. 
The  excavations  are  not  the  cause  of  the  general  symptoms  which 
disable  the  patient,  but  the  more  acute  patches  of  infiltration  in  other 
parts  of  the  lung  are  responsible  for  the  fever,  nightsweats,  etc.  Com- 
pressing these  parts  we  may  achieve  good  results.  In  these  cases  we 
hardly  ever  achieve  a  cure  with  pneumothorax,  because  the  cavity 
cannot  cicatrize  or  contract  owing  to  the  stiffness  of  its  walls  which, 
together  with  the  pleural  adhesions,  prevents  its  collapse  by  the  gas 
pressure.     But  they  may  be  greatly  relieved  by  a  pneumothorax. 

Duration  of  the  Treatment. — The  question  how  long  the  pneumo- 
thorax must  be  maintained  in  order  to  achieve  a  cure  cannot  be 
answered  categorically ;  no  rules  can  be  laid  down  which  will  apply  to 
all  cases.  In  fact,  considering  that  this  method  of  treatment  has 
been  applied  such  a  short  time,  there  are  few  who  have  many  cases 
under  observation  for  from  six  to  ten  years,  and  even  they  have  not 
agreed  as  to  the  usual  duration  of  treatment  of  a  successful  case.  The 
following  principles  are  based  on  the  experiences  of  Forlanini,  Brauer, 
and  Saugman,  who  have  had  patients  under  their  care  for  many  years, 
as  well  as  on  my  own  observations,  which  have  not  yet  extended  for 
a  sufficient  period  of  time  to  give  definite  conclusions. 

It  appears  that  we  cannot  count  on  less  than  two  years  in  the  most 
favorable  cases,  although  I  have  had  success  within  one  year  in  several 
cases — the  pneumothorax  was   allowed   to   be   absorbed   and   there 

1  Le  pneumothorax  artificiel  dans  le  traitement  de  la  tuberculose  pulmonaire,  Paris, 
1913. 


598     OPERATIVE   TREATMENT— ARTIFICIAL   PNEUMOTHORAX 

occurred  no  relapse  of  the  disease.  But  these  cases  are  few.  To  my 
mind,  the  most  difficult  problem  is  to  determine  when  the  healing 
process  has  been  completed,  so  that  if  the  lung  is  permitted  to  reexpand 
no  active  lesion  will  remain  to  flare  up  again  by  the  respiratory  move- 
ments. This,  however,  is  difficult  and,  I  believe,  impossible  to  deter- 
mine with  any  precision  as  long  as  there  is  complete  collapse  of  the 
lung,  and  the  general  condition  of  the  patient  is  good  because  of  the 
collapse.  Moreover,  if  we  allow  the  pneumothorax  to  be  absorbed  too 
early  there  may  not  only  be  a  relapse  of  the  disease,  but  experience  has 
shown  that  the  pleural  sheets  are  likely  to  adhere,  and  the  fibrous 
bands  prevent  the  formation  of  a  new  pneumothorax,  if  we  find  that 
this  is  indicated. 

It  is  for  this  reason  that  whenever  we  decide  to  discontinue  the  treat- 
ment we  must  watch  the  patient  carefully  while  the  gas  is  slowly  being 
absorbed,  and  if  some  symptoms  appear,  such  as  fever,  cough,  expectora- 
tion anorexia,  tachycardia,  etc.,  we  must  at  once  reinflate  the  pleura. 
Forlanini  says  that  many  patients  require  a  pneumothorax  "forever," 
which  is  undoubtedly  true,  and  most  authors  who  have  had  experience 
with  this  method  of  treatment  for  many  years,  and  had  opportunities 
to  observe  their  cases  for  long  periods  of  time,  agree  with  him. 

Saugman,  who  has  treated  numerous  cases  with  artificial  pneumo- 
thorax and  observed  them  for  many  years,  says  that  when  only  a 
partial  pneumothorax  has  been  created  which,  however,  has  had  a  good 
effect  on  the  symptomatology  of  the  disease  the  treatment  must  be 
continued  for  at  least  two  years,  often  for  a  longer  period,  according 
to  clinical  indications;  in  some  cases  "forever."  In  cases  in  which, 
complete  collapse  of  the  lung  was  attained,  we  may  expect  a  successful 
termination  in  one  year,  and  in  some  acute  cases  the  treatment  may 
be  discontinued  within  one  year.  Forlanini,  Brauer,  and  others  have 
had  in  some  cases  good  and  even  permanent  results  after  six  months' 
treatment.  It  is,  however,  better  to  continue  for  at  least  two  years 
in  all  cases.  In  chronic  cases  we  must  consider  two  years  as  the  abso- 
lutely shortest  period  of  treatment,  and  in  doubtful  cases  it  must  be 
prolonged  for  three  and  even  four  years.  The  inconvenience  to  the 
patient  in  having  infrequent  refills,  four  to  six  annually,  is  trifling 
considering  that  he  can  pursue  his  vocation,  compared  with  the 
hazards  of  a  relapse  in  case  the  lung  is  allowed  to  reexpand  too  early. 
It  is  therefore  better  to  continue  the  treatment  for  a  year  longer  than 
to  stop  one  month  too  early.  If  the  disease  is  extensive  it  is  advisable 
that  the  inflations  should  be  continued  over  long  periods  of  years, 
perhaps  "forever." 

Results  of  Pneumothorax  Treatment. — We  have  seen  that  hardly 
5  per  cent,  of  cases  of  phthisis  are  suitable  for  pneumothorax  treatment. 
In  other  words,  even  if  all  the  cases  subjected  to  the  operation  were 
cured,  which  is  not  the  case,  95  per  cent,  of  the  sufferers  from  this 
disease  are  not  suitable  for  the  treatment. 

In  suitable  cases,  especially  those  running  an  acute  course,  the 
effect  is  often  striking — the  fever  declines  and  with  it  the  symptoms 


RESULTS  OF  PNEUMOTHORAX  TREATMENT  599 

of  toxemia,  etc.  But  in  many  cases  the  improvement  is  not  permanent. 
One  of  the  compHcations,  Hke  pleural  effusion  in  more  than  50  per  cent, 
of  these  cases,  again  brings  about  fever  and  symptoms  of  toxemia, 
etc.  In  many  cases  we  are  finally  compelled  to  abandon  the  treatment 
because  after  the  pleural  effusion,  adhesions  prevent  the  introduction 
of  more  gas.  In  others,  a  lesion  in  the  untreated  side  flares  up  and 
gives  trouble,  as  might  be  expected.  In  still  others  the  lung  is  com- 
pressed all  over  excepting  the  upper  third,  where  the  main  lesion  is 
located,  because  there  it  is  held  by  some  dense  pleural  adhesions  which 
cannot  be  separated  by  increased  gas  pressure.  Autopsy  experience 
teaches  that  often  such  plural  adhesions  can  hardly  be  cut  with  a  knife. 

Under  the  circumstances  the  number  of  cases  cured  by  this 'method 
is  rather  small.  Statistics  which  can  be  considered  reliable  are  not 
available,  because  hardly  two  authors  have  reported  comparable 
material.  Lemke  and  others  treated  incipient  cases,  which  should 
not  be  done.  Others  treat  only  advanced  strictly  unilateral  cases; 
still  others  confine  the  treatment  to  cases  in  which  there  is  nothing 
to  lose,  etc. 

This  should  not  deter  us  from  applying  the  treatment  in  all  cases  in 
which  it  is  indicated.  We  must  always  bear  in  mind  that  in  "hopeless" 
cases  an  artificial  pneumothorax  often  saves  life,  gives  comfort  and  in 
some  even  efficiency,  which  cannot  be  obtained  by  any  other  method 
of  treatment  practised  at  present.  All  our  cancer  surgery,  of  which 
some  surgeons  speak  with  justifiable  pride,  does  not  give  results 
comparable  with  artificial  pneumothorax  in  hopeless  cases  of  phthisis. 
No  surgeon  hesitates  in  performing  the  operation  of  gastrostomy  for 
cancer  of  the  esophagus  or  stomach,  knowing  that  in  all  probability 
the  patient  will  not  survive  three  months.  Palliative  enterostomies, 
tracheotomies,  etc.,  are  performed  with  confidence  that  the  best  is 
done;  even  when  life  is  not  saved,  comparative  comfort  is  given 
during  the  last  days  of  life  of  the  unfortunate  patient.  In  hopeless 
cases  of  phthisis  artificial  pneumothorax  does  much  more  than  this 
palliative  surgery:  it  removes  the  symptoms  which  make  the  life  of 
the  patient  miserable — the  cough,  the  expectoration,  the  fever,  the 
nightsweats,  anorexia,  hemoptysis,  etc.;  reinvigorates  him,  and  in 
many  cases  renders  him  efficient  at  his  calling  or  even  to  do  some 
light  manual  labor,  irrespective  whether  he  is  ultimately  cured  or  not. 
The  only  inconvenience  it  puts  him  to  is  that  he  must  report  every 
month  or  six  weeks  for  a  refill,  which  he  knows  from  personal  expe- 
rience is  painless  and  bearable.  In  some  cases  artificial  pneumothorax 
is  more  than  palliative — it  cures  the  disease  radically  and  should 
therefore  be  applied  in  all  cases  where  other  methods  of  treatment 
have  been  tried  but  found  wanting.  Those  who  have  treated  many 
cases  have  seen  many  who  have  become  self  supporting  at  manual  labor 
while  under  treatment.  M.  E.  Rist^  gives  the  history  of  a  patient 
with  an  artificial  pneumothorax  who  withstood  the  hardships  of  war 
unscathed. 

1  Presse  Medicale,  1914,  xxii,  692. 


600      OPERATIVE   TREATMENT— ARTIFICIAL   PNEUMOTHORAX 

Other  Surgical  Operations  for  Phthisis. — Extrapleural  Pneumolysis. 

— Artificial  pneumothorax  is  not  the  only  method  of  surgical  treat- 
ment of  pulmonary  tuberculosis.  There  have  been  suggested  opera- 
tions for  the  release  of  the  compressed  apex  of  the  lung  by  the  shortened 
first  rib  and  ossified  cartilage  (p.  84);  also  injections  of  medication 
right  into  the  lesion  in  the  lung.  Th.  Tuffier/  in  France,  and  Baer^ 
and  Sauerbruch,^  in  Germany,  have  developed  the  operation  of  extra- 
pleural pneumolysis  with  a  view  of  compressing  the  affected  area  of 
the  lung.  The  object  is  practically  the  same  as  that  of  artificial 
pneumothorax,  but  with  this  operation  only  the  affected  part  of  the 
lung  is  compressed  while  the  rest  of  the  parenchyma  is  left  physio- 
logically active.  It  can  also  be  applied  in  cases  in  which  pneumothorax 
cannot,  as  when  dense  pleural  adhesions  prevent  the  injection  of  air 
or  nitrogen  into  the  pleura. 

A  small  piece  of  rib  is  resected  over  the  tuberculous  lesion,  or  the 
phthisical  cavity  which  is  surrounded  by  a  thick  fibrous  wall,  and  an 
adherent  pleura  which  prevent  its  shrinkage.  The  lung  with  both 
sheets  of  the  pleura  is  then  separated  from  the  chest  wall  between  the 
costal  pleura  and  the  endothoracic  fascia.  The  lung  is  then  collapsed 
so  that  the  walls  of  the  cavity  are  brought  into  apposition.  The 
space  thus  created  under  the  chest  wall  is  filled  in  with  Beck's  bismuth 
paste,  bismuth  paraffin,  or  plain  paraffin;  Tuffier  uses  adipose  tissue, 
fresh  or  preserved.  The  wound  is  then  closed  properly.  Xo  general 
anesthesia  is  used,  because  while  squeezing  out  the  secretions  of  the 
pulmonary  cavity  the  lungs  may  be  flooded,  and  aspiration  pneumonia 
may  be  the  result.  But  local  anesthesia  is  sufficient  according  to  those 
who  practise  the  operation. 

Tuffier  urges  this  operation  even  in  incipient  cases,  saying  that  we 
should  not  wait  in  phthisis  till  a  cavity  has  formed,  any  more  than  we 
wait  in  tuberculous  diseases  of  joints  till  suppuration  or  fistulse  have 
set  in.  But  the  modern  treatment  of  tuberculous  joint  disease  is 
rather  conservative,  and  results  are  obtained  which  are  superior  to 
those  obtained  with  operative  treatment.  It  is  doubtful  whether  the 
operation  of  extrapleural  pneumolysis  will  ever  become  as  popular  as 
that  of  artificial  pneumothorax. 

Phrenikotomie. — Another  operation  which  has  been  suggested  for 
the  cure  of  phthisis  is  resection  of  the  phrenic  nerve  with  a  view  of 
procuring  rest  of  the  lower  part  of  the  lung  by  paralysis  of  the  dia- 
phragm on  the  affected  side.  F.  Sauerbruch^  and  Stuertz  have  done 
this  operation  in  Europe  and  Ralph  C.  ^Nlatson  and  ^Nlarr  Bisaillon^ 
have  reported  2  cases  in  this  country.  It  appears  from  the  few  cases 
reported  that  the  operation  is  of  no  therapeutic  value,  if  only  because 
the  diaphragm  remains  mobile  with  the  respiratory  movements  after 
the  operation. 

1  Paris  Medical,  1914,  iv,  231;    Interstate  Med.  .Jour..  1914,  xxi,  259. 

2Ztschr.  f.  TuberkuJose,   1914,  xxiii,  209. 

3  Beitr.  z.  klin.  Chirurgie,  1914,  xc,  247.  ^  Miinch.  mod.  Wchnschr.,  1913,  Ix,  625. 

5  Trans.  Nat.  Assn.  Study  and  Prev.  Tuber.,  1915,  xi,  183. 


CHAPTER  XL. 

GENERAL  TREATMENT  OF  THE  VARIOUS  FORMS 
OF  PULMONARY  TL^ERCULOSIS. 

Incipient  Phthisis. — The  treatment  of  the  early  stage  of  phthisis, 
immediately  after  its  recognition,  varies  with  the  intensity  of  the 
clinical  manifestations  of  the  disease.  We  have  shown  that  a  large 
proportion  of  cases  manifest  a  strong  tendency  to  spontaneous  cm-e; 
the  disease  is  "aborted"  within  a  few  months.  These  patient^  need 
no  treatment  beyond  stopping  work,  keeping  regular  hours,  increas- 
ing the  quantity  of  food  ingested,  etc.  A  stay  in  the  country  for  a 
month  or  two  is  even  better.  In  most  cases  of  this  type  institutional 
treatment  is  not  advisable;  in  fact  I  have  seen  some  who  were  decid- 
edly harmed  by  a  stay  in  a  sanatorium,  where  they  were  trained  into 
carefully  studying  their  disease,  and  impressed  with  the  dangers  of 
slight  fever,  fatigue,  etc.  Some  have  not  been  as  industrious  after  the 
"cure"  as  before,  though  their  state  of  health  left  little  to  be  desired. 
With  workmen  having  dependent  families  this  is  an  important  point. 

It  is  different  with  patients  in  whom  the  disease  manifests  a 
tendency  to  acute  progress;  who  have  fever,  nightsweats,  cough, 
anorexia,  emaciation,  etc.  These  are  to  be  given  complete  rest  of 
mind  and  body  till  the  acute  symptoms  are  relieved.  The  best  way 
of  attaining  this  depends  on  the  financial  resources  of  the  patient. 
The  well-to-do  may  be  treated  at  home  or  sent  to  private  sanatoriums. 
The  results  in  either  case  will  be  the  same  in  the  vast  majority  of 
cases.  Under  no  circumstances,  however,  should  a  patient  with  pyrexia 
be  sent  to  the  country,  unless  he  can  afford  to  take  along  a  well- 
trained  nurse,  and  will  have  competent  medical  advice.  Febrile 
patients,  who  cannot  satisfy  these  two  requirements  are  best  treated 
at  home,  even  if  the  home  is  only  half-way  satisfactory. 

The  principles  of  the  rest  cure,  as  well  as  of  the  treatment  of  pyrexia, 
have  been  given  in  detail  elsewhere.  Patients  who  cannot  be  managed 
at  home  along  these  lines  should  be  sent  to  sanatoriums. 

Patients  with  limited  means  should  invariably  be  sent  to  institu- 
tions for  the  first  few  months  of  the  disease,  unless  they  can  be  moved 
into  good  homes  where  they  may  have  appropriate  rooms  for  them- 
selves to  carry  out  the  rest  and  open-air  treatment.  But  after  remain- 
ing in  the  institutions  for  the  period  of  pyrexia,  they  may  return  home 
where  they  may  be  cared  for  just  as  well  as,  and  at  less  cost  than,  in 
the  sanatoriums.  Those  who  have  no  relatives  or  friends  able  and 
willing  to  give  them  a  proper  home  should  remain  in  the  institutions 


602       GENERAL   TREATMENT  OF  PULMONARY  TUBERCULOSIS 

till  the  arrest  of  the  disease  is  assured.  As  was  already  stated  in  Chap- 
ter XXXIY,  the  results  are  the  same  with  home  or  institutional  treat- 
ment, if  the  same  amount  of  money  is  spent  upon  the  patient  in 
either  case. 

Reasonable  patients,  running  only  a  subfebrile  temperature,  may  be 
sent  to  the  country  for  the  first  few  months  of  the  disease.  Many 
improve  to  an  astonishing  degree,  and  are  cured  if  the  disease  is  of 
the  milder  or  abortive  variety.  All  patients  should  be  sent  out  of  town, 
preferably  to  the  mountains,  if  there  are  no  contra-indications,  for 
the  hot  summer  months.  During  the  winter  most  phthisical  patients 
do  well  in  the  city. 

The  dietetics  of  phthisis  has  already  been  detailed  in  Chapter  XXXV. 
But  it  should  again  be  emphasized  that  patients  with  a  good  appetite 
and  digestion  need  no  special  diet,  except  that  they  should  eat  more 
than  they  had  been  accustomed  to  before  the  onset  of  the  disease. 
In  many  cases  an  increase  in  the  quantity  of  proteins  and  fats  is 
desirable.  Those  with  anorexia  and  indigestion  are  to  be  treated  for 
these  conditions,  because  good  gastro-intestinal  functions  are  the 
best  assets  of  the  phthisical  patient.  A  poor  appetite,  if  not  improved 
by  open-air  treatment,  should  be  stimulated  with  some  of  the 
stomachic  bitters;  creosote  in  small  doses  is  even  better  for  this  purpose 
in  many  cases.  For  indigestion  appropriate  dietetic  and  medicinal 
treatment  is  to  be  instituted. 

In  the  vast  majority  of  cases  medicinal  treatment  is  not  necessary 
in  incipient  phthisis,  unless  it  is  for  the  relief  of  annoying  symptoms. 
Cough  may  be  controlled  b}'  the  administration  of  creosote  in  moderate 
doses.  In  rare  cases  sedatives — codein,  heroin,  dionin,  etc. — must  be 
given  in  accordance  with  the  indications  discussed  in  Chapter  XXXVI. 
Anemia  is  to  be  treated  with  iron  and  arsenic.  In  fact  most  patients 
treated  at  home  should  be  given  some  medication,  even  if  it  is  only  a 
placebo,  and  for  its  psychic  effect  alone.  But  there  is  no  doubt  that 
ichthyol,  creosote  and  arsenic,  given  intelligently,  exert  a  good  influ- 
ence on  the  course  of  the  disease. 

The  treatment  of  complications  and  special  symptoms,  such  as 
hemoptysis,  nightsweats,  emaciation,  etc.,  has  been  discussed  else- 
where. 

^Nlost  patients  in  the  incipient  stage  of  the  disease  do  well  under  the 
mode  of  treatment  just  outlined.  ^Nlany  will  recover  within  a  few 
months;  in  a  large  proportion  the  disease  will  be  arrested,  but  they 
are  liable  to  suffer  from  relapses  sooner  or  later.  In  many  the  dis- 
ease will  continue  its  onward  march,  irrespective  of  the  treatment 
applied.    We  then  have  the  so-called  advanced  stage. 

Advanced  Phthisis. — The  zeal  displayed  by  medical  men  during 
recent  years  to  discover  and  treat  early  cases  has  resulted  in  neglect  of 
those  in  whom  the  lesion  has  advanced  beyond  the  stage  which  by 
common  consent  is  called  incipient.  Hospital  wards  for  advanced 
phthisis  are  often  attended  in  a  haphazard  fashion,  and  the  patients 


MEDICINAL   TREATMENT        ,         '  603 

are  discouraged  to  a  pitiable  extent.  Patients  in  the  advanced  stages 
are  usually  told  by  their  medical  advisers  to  go  to  some  distant 
climatic  resort,  irrespective  of  their  condition.  This  is  all  wrong. 
There  is  as  much  hope  for  the  average  patient  in  the  moderately 
advanced  stage,  as  for  a  large  proportion  of  incipient  patients.  Indeed 
we  have  already  emphasized  the  fact  that  the  prognosis  in  advanced 
phthisis  depends  less  on  the  age  and  extent  of  the  lesion  than  on  the 
acuteness  and  activity  of  the  process. 

A  patient  with  an  advanced,  especially  cavitary  lesion,  owing  to 
the  fact  that  he  has  survived  the  incipient  stage,  proves  that  he  has  a 
certain,  but  variable,  amount  of  inherent  resistance  against  the  ravages 
of  phthisis.  It  is  our  aim  to  preserve,  or  rather  to  increase  this  power 
of  resistance.  This  can  only  be  done  by  proper  regulation  of  diet,  rest 
and  exercise,  and  by  avoiding  indiscretions  which  are  liable  to  produce 
acute  exacerbations  of  the  tuberculous  process. 

We  therefore  regulate  the  diet  of  the  patient  in  such  a  manner 
that  he  will  not  lack  in  assimilable  nourishment  (see  p.  513).  The 
question  of  rest  and  exercise  is  regulated  under  the  guidance  of  the 
thermometer  and  the  pulse  rate.  In  hopeful  cases  all  efforts  are  to 
be  directed  at  avoiding  febrile  exacerbations,  or  rendering  them  short 
lived  if  they  occur.  Many  of  the  afebrile  patients  may  make  them- 
selves useful  in  some  direction.  Some  may  even  work  at  their  occu- 
pations, provided  we  find  that  they  are  not  harmed  by  activity.  The 
fact  that  one  has  cavities  in  his  lung  does  not  mean  that  he  is  disabled. 
Patients  engaged  in  vocations  involving  no  undue  muscular  exertion 
may  be  very  eflficient.  All  should  do  something  when  strong  enough 
to  do  it,  but  must  cease  all  activities  as  soon  as  they  .feel  fatigued, 
have  fever,  etc.  This  policy  has  during  recent  years  been  adopted  in 
all  the  enlightened  institutions  for  the  care  of  the  tuberculous,  and 
the  patients  have  benefited  much  more  than  by  the  previous  routine 
rest  treatment,  carried  out  indiscriminately. 

The  diet  in  advanced  phthisis  is  to  be  nutritious  and  of  a  character 
that  will  not  overtax  the  digestive  organs.  At  the  least  indication 
of  indigestion  the  diet  should  be  appropriately  corrected,  because, 
next  to  fever,  indigestion  is  most  liable  to  hurt  the  patient  irreparably. 
Those  manifesting  a  tendency  to  obesity,  and  they  are  not  as  infre- 
quent as  is  commonly  believed,  should  restrict  the  ingestion  of  fats 
and  carbohydrates.  A  fat  consumptive  is  often  more  miserable  than 
a  lean  one. 

Medicinal  Treatment. — The  average  patient  is  not  satisfied  with 
hygienic  and  dietetic  treatment,  and  when  no  medicinal  substances  are 
administered  he  is  apt  to  be  led  to  the  belief  that  there  is  no  remedy 
for  him.  But  there  are  drugs  which  have  a  beneficial  influence  on  the 
course  of  the  disease,  as  was  shown  elsewhere  (Chapter  XXXVI) ,  and 
medication  should  be  administered.  Considering  that  the  patient  will 
have  to  be  kept  under  control  for  months,  it  is  often  difficult  to  allay 
his  apprehensions,  and  retain  his  confidence  till  the  termination  of 


604      GENERAL   TREATMENT  OF  PULMONARY  TVBERCVLOSI^ 

the  case.  It  is  also  a  fact,  to  which  we  have  already  alluded,  that 
while  many  remedies  have  an  excellent  influence  on  the  disease  or  the 
patient,  they  retain  their  potency  for  but  a  short  time,  as  a  rule.  The 
same  is  true  of  climatic  resorts  and  institutions.  The  patients  gain 
best  during  the  first  two  or  three  months'  treatment. 

For  these  reasons  medication  must  often  be  changed.  Renon's 
suggestion  may  be  followed:  The  patient  is  given  a  course  of  several 
weeks  with  a  certain  remedy  and  then  it  is  changed  for  another 
medicament  administered  for  several  weeks.  The  results  are  often 
remarkable:  There  are  gains  in  general  health,  the  lesion  in  the  lung 
shows  signs  of  cicatrization,  and  the  patient  is  encouraged.  ^Ye  may 
thus  achieve  the  same  results  as  with  tuberculin  without  incurring 
the  hazards  of  this  dangerous  substance.  A  good  method  is  to  begin 
with  ichthyol,  administered  as  directed  in  Chapter  XXXVI  for  four  or 
six  weeks;  or  if  the  patient  thrives  on  it,  it  may  be  continued  longer. 
For  a  week  or  two  it  is  given  in  solution;  for  another  fortnight  in 
capsules,  etc.  Then  we  may  give  him  creosote  or  one  of  its  derivatives 
— creosote  or  guaiacol  carbonate,  combined  with  arsenic  for  several 
weeks.  These  substances  may  be  given  in  mixtures,  pills,  globules, 
capsules,  or  by  inhalation,  as  suggested  by  Beverly  Robinson  (see  p. 
529) .  The  arsenic  may  be  combined  Avith  the  creosote,  or  given  alone 
in  the  form  of  Fowler's  solution  or  in  pill  form.  Of  course,  if  there  is 
a  tendency  to  hemoptysis  neither  the  creosote  nor  the  arsenic  is  to 
be  given.  The  glycerophosphates  are  also  beneficial  and  may  be  given 
in  appropriate  doses.  They  exert  an  excellent  influence  on  the  tuber- 
culous process,  promote  nutrition,  improve  the  blood  picture,  etc. 

Medication  should  be  discontinued  as  soon  as  there  is  pyrexia, 
though  when  the  temperature  is  below  100°  F.  medication  may  and 
should  be  given. 

In  addition  to  the  above  there  is  to  be  given  medication  according 
to  indications  as  revealed  by  the  symptoms.  The  anorexia,  night- 
sweats,  constipation,  diarrhea,  etc.,  call  for  certain  medicinal  treatment 
which  has  already  been  discussed  under  symptomatic  treatment. 

In  this  manner  the  average  tuberculous  patient  may  get  along  very 
well  for  years.  Some  have  very  long  periods  of  quiescence,  and  are 
only  rarely  laid  up  with  acute  exacerbations  which  need  special  treat- 
ment, as  any  acute  condition.  But  they  soon  recuperate,  as  a  rule, 
and  again  feel  well  for  a  variable  period.  While  many  survive  acute 
exacerbations  occurring  at  infrequent  intervals,  provided  proper 
treatment  is  promptly  instituted,  in  most  of  the  chronic  cases  one  of 
these  acute  exacerbations  finally  ends  fatally.  ]Many  succumb  to 
intercurrent  diseases.  These  periods  of  quiescence  may  be  obtained 
by  judicious  home  treatment  just  as  well  as  by  institutional  treatment, 
unless  we  are  prepared  to  keep  patients  in  sanatoriums  for  many  years, 
irrespective  of  the  activity  of  the  disease. 

Cases  manifesting  a  tendency  to  progression,  with  acute  or  sub- 
acute symptoms  and  unilateral  lesions,  should  be  treated  with  artificial 


TREATMENT  OF  CONVALESCENT  AND  ARRESTED  CASES     605 

pneumothorax.  It  offers  immediate  relief  of  the  symptoms,  and  shows 
more  striking  and  lasting  results  than  any  other  mode  of  treatment  of 
active  and  progressive  phthisis.  Many  of  the  less  acute  cases  are 
also  proper  subjects  for  pneumothorax.  The  indications  and  contra- 
indications are  discussed  in  Chapter  XXXIX. 

Some  cases  show  activity  of  the  process  despite  the  careful  treatment. 
All  efforts  at  raising  the  resisting  forces  are  unavailing  and  the  disease 
progresses  to  a  more  or  less  speedy  termination.  All  we  can  do  is  to 
apply  symptomatic  treatment  and  to  render  the  last  weeks  or  days 
bearable  and  painless.  The  solacing  effects  of  the  derivatives  of  opium 
should  not  be  denied  these  unfortunates.  It  is,  however,  one  of  the 
most  common  mistakes  to  send  these  patients  to  the  country,  or  to 
sanatoriums.  If  such  a  patient  has  a  home  in  which  there  are  no 
infants,  he  may  remain  there.  If  his  financial  resources  are  limited, 
the  proper  place  is  a  hospital  for  consumptives.  We  are  at  times 
surprised  that  under  proper  care  even  the  most  desperate  case  recu- 
perates, and  within  a  few  months  returns  greatly  improved.  Rarely, 
they  even  regain  a  capacity  for  working. 

Treatment  of  Convalescent  and  Arrested  Cases. — A  large  propor- 
tion of  tuberculous  patients  in  the  advanced  stages  of  the  disease 
improve  to  an  extent  as  to  become  useful  at  their  respective  occupa- 
tions, although  they  have  not  been  cured.  They  cough,  expectorate, 
at  times  the  sputum  no  longer  contains  any  more  tubercle  bacilli,  are 
more  or  less  emaciated,  but  they  have  no  fever,  no  tachycardia,  etc. 
Physical  exploration  of  the  chest  shows  that  there  are  cavities  in 
the  lungs,  some  displacements  of  the  thoracic  viscera,  etc.  Many  of 
these  are  well  able  to  take  care  of  themselves  and  even  to  be  efficient 
at  some  easy  occupation.  Under  proper  medical  supervision  they  may 
keep  on  in  this  condition  for  years,  even  for  their  natural  lives.  It  is 
very  important  that  these  patients  have  some  occupation,  otherwise 
they  are  liable  to  brood  over  their  condition  and  become  actual  hypo- 
chrondriacs.  The  dependent  ones  are  liable  to  intrench  themselves  in 
hospitals  and  stay  there  indefinitely;  when  discharged  they  soon  seek 
admission  to  another  one.  They  are  very  costly  to  the  community, 
as  well  as  to  those  depending  on  them.  The  fact  that  one  has  a  cavity 
in  the  lungs  does  not  mean  that  he  is  disabled  from  working  any  more 
than  one  who  has  a  chronic  fistula  or  sinus  in  another  part  of  the  body. 
It  is  the  intensity  of  the  constitutional  symptoms  which  should  be  the 
guide  in  these  matters,  and  not  the  findings  on  physical  exploration 
of  the  chesti 

Once  one  has  suffered  from  chronic  phthisis  of  some  duration, 
he  is  never  cured  in  the  anatomical  sense;  he  is  always  in  danger  of 
a  relapse.  He  should  be  impressed  with  the  fact  that  all  that  was 
attained  was  an  arrest  of  the  process,  and  that  there  may  be  at  any 
time  a  recrudescence  of  the  disease  with  even  greater  vigor  than  the 
former  attack.  These  arrested  cases  should  remain  under  medical 
supervision  for  several  years,  and  examined  periodically;    first  fre- 


606      GENERAL  TREATMENT  OF  PULMONARY  TUBERCULOSIS 

quently,  then  at  less  frequent  intervals,  so  that  any  tendency  to  a 
relapse  may  be  checked  early  by  proper  treatment.  While  all  efforts 
are  to  be  directed  toward  prevention  of  excessive  introspection  and 
hypochondriasis,  yet  patients  with  arrested  disease  should  be  in- 
structed as  to  the  significance  of  certain  symptoms,  such  as  cough, 
fever,  nightsweats,  loss  of  weight,  etc.  During  intercurrent  diseases, 
especially  catarrhal  conditions  of  the  upper  respiratory  passages, 
and  influenza,  they  are  to  drop  all  work  and  take  a  complete  rest. 

A  patient  with  arrested  disease  should  live  in  a  healthy  part  of  the 
city,  in  a  good  home,  and  sleep  in  a  room  with  open  windows.  He 
may  engage  in  his  former  occupation,  excepting  the  dangerous  ones, 
but  the  workshop  must  be  of  the  modern  and  sanitary  type,  with 
good  ventilation,  etc.  When  possible,  workmen  should  become 
gardeners,  conductors,  watchmen,  chauffeurs,  letter  carriers,  etc.  When 
feasible  it  is  advisable  that  they  take  up  farming.  Well-to-do  patients 
may  move  out  of  the  city  and  settle  for  life  in  the  country.  Others 
may  live  in  the  suburbs,  or  in  any  country  place,  where  they  can  find- 
suitable  employment^  Those  who  remain  in  the  city  should  avoid  all 
indiscretions.  The  questions  of  marriage,  pregnancy,  and  lactation 
have  already  been  discussed. 

Acute  Phthisis. — The  acute  forms  of  phthisis  are  to  be  treated 
symptomatically,  according  to  indications,  as  long  as  we  have  no 
specific  for  tuberculosis.  In  the  pulmonary  type  of  acute  miliary 
tuberculosis  careful  hygienic  and  dietetic  treatment  is  indicated. 
The  nursing  is  of  special  importance,  if  we  are  to  make  the  last  days 
of  the  patient  more  or  less  comfortable.  The  treatment  is  the  same 
as  of  any  other  acute  or  malignant  infectious  disease. 

Acute  pneumonic  phthisis  is  not  invariably  fatal;  often  the  patient 
passes  the  acute  stage  and  becomes  a  chronic  consumptive  and  the 
treatment  is  then  the  same  as  that  given  above  for  chronic  phthisis. 

During  the  acute  stage  the  patient  is  to  be  kept  in  bed,  given  food 
suitable  for  a  febrile  case,  and  the  indications  are  otherwise  met  as  they 
arise.  If  the  acuteness  of  the  process  abates,  the  patient  remaining 
with  an  active  cavity,  climatic  treatment  may  be  tried.  Some  of  these 
patients  do  very  well  when  removed  from  home  to  some  place  in  the 
country,  irrespective  of  its  location  or  altitude.  But  they  usually  need 
a  nurse  or  an  attendant.  The  practice  of  sending  such  patients  to 
shift  for  themselves  in  the  country  cannot  be  too  severely  censured. 
It  is  unfortunate  that  public  sanatoriums  do  not  admit  this  class  of 
cases. 

Fibroid  Phthisis. — The  patient  may  feel  well  and  be  efficient  at 
his  occupation  for  many  years,  and  the  treatment  at  this  period  is 
purely  symptomatic.  It  is,  however,  imperative  to  impress  on  them 
that  overexertion  and  indiscretions  are  apt  to  activate  the  process. 

Many  patients  with  fibroid  phthisis  are  well  nourished  during  the 
latent  or  quiescent  stage  of  the  disease  and  need  no  special  dietetic 
instructions.     But  we  often  meet  with  persons  suft'ering  from  active 


PULMONARY  TUBERCULOSIS  IN  CHILDREN  G07 

or  quiescent  fibroid  phthisis  who  suffer  from  obesity.  The  dyspnea, 
which  is  a  marked  symptom  in  this  disease,  is  more  severe  in  the  fat 
consumptive  and  it  is  advisable  to  arrange  the  diet  so  that  the  patient 
does  not  gain  in  weight  excessively.  Exceptionally,  it  is  even  neces- 
sary to  reduce  the  amount  of  carbohydrates  and  fats  with  a  view 
of  reducing  the  weight  of  the  patient.  In  my  experience  the  lean, 
even  emaciated  individuals  suffering  from  fibroid  phthisis  are  more 
comfortable,  and  live  longer  than  those  who  are  obese. 

In  many  cases  the  iodides  are  very  good.  The  dyspnea  is  very  often 
relieved,  expectoration  is  facilitated,  and  the  general  condition  of  the 
patient  improves  by  the  administration  for  several  months  of  potas- 
sium iodide  or  some  of  the  newer  albuminate  compounds  of  iodin. 
But  this  remedy  should  not  be  given  during  febrile  attacks,  which  are 
not  frequent  in  this  disease.  When  fever  appears  and  is  persistent, 
the  disease  differs  but  little  from  common  chronic  phthisis.  Those 
who  are  subject  to  hemoptysis,  and  riiany  fibroid  patients  suffer  from 
recurrent  hemoptysis  of  varying  severity,  should  not  be  given  any 
iodides.  It  should  be  discontinued  immediately  at  the  appearance  of 
streaky  sputum.  In  many  cases  with  profuse  expectoration,  creosote 
gives  relief. 

When  signs  of  asystole  make  their  appearance,  with  dyspnea, 
edema,  etc.,  appropriate  doses  of  digitalis,  strophanthus,  etc.,  should 
be  administered. 

Fibroid  patients  should  take  frequent  vacations.  The  mountains 
are  not  suitable  for  them  because  these  patients  are  more  short-winded 
the  higher  the  altitude.  It  is  best  to  send  them  to  the  plains,  or  the 
seacoast.  Many  do  very  well  indeed  in  a  desert  climate,  provided 
they  can  adapt  themselves  to  the  surroundings,  or  "rough  it." 

In  the  later  stages,  when  fever,  nightsweats,  cough,  anorexia,  etc. 
ensue,  the  case  is  one  of  advanced  chronic  phthisis  and  is  to  be  treated 
accordingly. 

Pulmonary  Tuberculosis  in  Children. — The  acute  types  of  tubercu- 
losis in  infants  are  hopeless  and  the  treatment  is  purely  symptomatic. 
The  infant  is  to  be  cared  for  as  a  case  of  pneumonia  at  that  age.  The 
only  useful  thing  we  can  do  for  infants  less  than  one  year  old  is  to 
prevent  infection  with  tubercle  bacilli.  Once  this  has  occurred,  the 
prognosis  is  very  unfavorable. 

We  have  seen  that  chronic  pulmonary  tuberculosis  of  the  type 
common  in  adults  is  practically  unknown  among  children  under  ten 
years  Df  age.  In  them  the  disease  manifests  itself  as  hematogenic, 
affecting  the  glands,  bones  and  joints,  and  is  then  the  province  of 
the  surgeon,  though  it  appears  from  all  available  data  that  hygienic 
and  dietetic  treatment  has  achieved  better  results  than  the  knife  in 
these  cases.  The  physician  encounters  in  children  disease  of  the 
tracheobronchial  glands.  Considering  that  death  due  to  this  disease 
is  very  rare,  it  is  clear  that  it  is  bearable  by  most  children.  The 
only  problem  is  whether  they  are  all  destined  to  develop  phthisis 


608       GENERAL   TREATMENT  OF  PULMONARY   TUBERCULOSIS 

when  reaching  the  age  of  adolescence,  or  later.  This  has  not  yet 
been  solved  to  the  satisfaction  of  all  who  are  entitled  to  judge. 

The  treatment  of  tracheobronchial  adenopathy  aims  at  assisting 
nature  in  its  efforts  to  preserve  the  child.  This  can  best  be  done  by 
doing  away,  as  far  as  possible,  with  the  unnatural  method  of  raising 
children.  Growing  children  should  not  be  kept  indoors  the  greater 
part  of  the  day  and  night,  but  should  be  urged  to  indulge  in  outdoor 
exercises  and  games.  Especially  is  outdoor  life  imperative  w^hen  a 
child  shows  signs  of  tuberculous  infection,  or  of  tracheobronchial 
adenopathy.  These  children  should  spend  the  greater  part  of  the  day 
outdoors,  and  sleep  in  rooms  with  open  windows.  If  they  can  be 
raised  in  the  country  it  is  much  better.  But  in  every  city,  excepting 
the  parts  known  as  the  "slums,"  children  may  enjoy  outdoor  life  and 
benefit  by  it. 

It  must  be  borne  in  mind  that  children  are  easily  adaptable  to  life 
in  cold  air,  and  most  of  them  can  run  around  the  street  w4th  scanty 
clothing  during  very  cold  days  and  derive  great  benefit.  They  can 
also  be  given  cold  spongings  followed  by  friction  wdth  a  rough  towel 
every  morning,  and  thus  "hardened."  Only  in  this  manner  can 
"colds"  be  prevented  in  children.  Harmless  in  themselves,  colds  may, 
in  children  with  tuberculous  glands  in  the  chest,  activate  the 
tuberculous  process  and  favor  an  acute  exacerbation  of  the  dormant 
tuberculous  process. 

The  ideal  treatment  of  tuberculous  children  is  to  raise  them  all  in 
the  country.  But  like  all  ideals,  it  is  only  attainable  by  the  favored 
few.  The  vast  majority  of  infected  children  have  to  be  raised  in  the 
cities,  for  obvious  reasons.  But  society,  which  is  largely  responsible 
for  the  conditions  favoring  tuberculous  infection,  can  do  a  great  deal 
toward  saving  these  children  and  raising  them  toward  healthy  man- 
hood and  womanhood,  by  providing  vacations  for  them  once  or  twice 
annually  so  that  they  may  recuperate  their  vanishing  forces  and  acquire 
resistance  against  the  extension  of  the  tuberculous  process.  In  New 
York  City  this  is  done  for  a  limited  number  of  children  derived  from 
tuberculous  stock  by  the  Preventorium.  In  other  cities  in  this  country 
similar  efforts  have  been  made.  But  not  all  that  need  these  vacations, 
proper  food,  and  exercises  are  accommodated  in  any  city. 

If  the  parents  of  a  child  with  tracheobronchial  adenopathy  can 
afford  it  they  should  move  to  the  country,  or  to  a  suburb.  In  some 
cases  it  is  feasible  to  send  the  child  to  be  raised  outside  of  the  city  lines. 
Many  authorities  maintain  that  it  is  best  to  raise  these  little  patients 
in  the  mountains,  or  that  they  should  be  sent  for  frequent  vacations 
to  a  high  altitude.  But  I  have  seen  excellent  results  in  many  cases 
which  were  sent  to  the  seacoast,  or  to  some  forest  climate.  It  is 
remarkable  how  quickly  these  children  recuperate  after  a  few  weeks 
out  in  the  open  air  away  from  the  city. 

]\Iany  of  these  children  do  not  eat  enough,  and  the  emaciation 
resulting  from  the  smouldering  tuberculous  process  in  the  chest  is 


PULMONARY   TUBERCULOSIS  IN  CHILDREN  609 

increased  by  the  lack  of  nourishment.  The  anorexia  is  very  often 
reheved  by  open-air  hfe.  A  child  in  the  city  ma}^  not  eat  enough,  or 
have  an  actual  abhorrence  for  food.  But  as  soon  as  it  is  removed 
to  the  country,  the  desire  for  food  is  increased;  often  the  appetite 
becomes  ravishing  a  few  days  after  arrival  in  the  country. 

In  those  who  cannot  afford  to  go  to  the  country  the  anorexia  may  be 
relieved  by  open-air  life  in  the  city.  They  should  be  urged  to  spend 
the  greater  part  of  the  day  outdoors  and  sleep  in  a  room  with  open 
windows.  In  urgent  cases  there  should  be  no  schooling.  The  modern 
open-air  schools  are  of  questionable  utility,  especially  during  the 
winter  when  the  bitter  cold  is  apt  to  prove  unbearable  to  both  the 
teachers  and  the  pupils.  The  child  needs  not  only  fresh  air,  but  exer- 
cise is  just  as  important.  This  keeps  the  child  warm  in  the  coldest 
day.  I  have  very  little  confidence  in  the  educational  value  of  the  open- 
air  classes;  so  far  as  I  have  observed,  there  is  hardly  any  study  during 
cold  days.  A  child  run  down  to  such  an  extent  as  to  need  open-air 
life  throughout  the  day  and  night  is  unfit  for  schooling  and  should  be 
taken  out  to  the  country  for  a  few  months  or  a  season,  or  taken  out  of 
school  for  a  similar  period,  till  it  recuperates,  when  it  may  resume 
studies. 

The  food  of  these  children  need  not  differ  from  that  suitable  for 
any  child  of  the  same  age,  but  it  should  be  plentiful,  appetizing,  and 
nourishing.  It  is  even  more  difficult  to  place  a  child  on  a  special  diet 
than  an  adult.  And  there  is  no  special  need  for  such  a  procedure.  It 
is,  however,  important  to  see  to  it  that  it  does  consume  a  sufficient 
quantity  of  proteids  and  fats.  In  children  between  two  and  four  years 
of  age,  milk,  cream  and  eggs  supply  these  requirements  ideally.  But 
older  children  should  be  urged  to  eat  meats  and  poultry,  and  butter 
is  the  best  source  of  fat  for  them.  It  is  the  most  assimilable  form  of 
fat  that  can  be  given  to  the  vast  majority  of  children.  Those  who  do 
not  thrive  on  this  diet,  or  who  will  not  take  a  sufficient  amount  of 
butter,  should  be  given  cod-liver  oil.  The  vast  majority  of  children 
take  it  pure,  or  with  malt.  Most  of  the  emulsions  contain  very  little 
of  the  oil  and  are  nauseous. 

Children  with  enlarged  bronchial  glands  will  almost  invariably  do 
well  under  this  mode  of  treatment.  It  is  often  astonishing  to  watch 
the  recuperation  of  an  emaciated  child  within  one  or  two  months  after 
being  placed  under  this  treatment.  It  is  encouraging  to  watch  the 
great  improvement  shown  by  most  of  the  children  taken  from  the 
tenements  of  New  York  City  to  the  country  or  Preventorium.  In 
some  obstinate  cases  it  is  necessary  to  repeat  the  vacation  twice 
annually  for  several  years.  Some  should  be  kept  out  of  town  till  they 
reach  adolescence.  But  it  should  always  be  remembered  that  they  all 
do  well  if  properly  treated;  the  development  of  chronic  phthisis  before 
the  age  of  ten  is  exceedingly  rare,  and  infrequent  before  the  age  of 
fifteen. 

There  is,  however,  one  danger  to  which  these  children  are  exposed. 
39 


610       GENERAL   TREATMENT  OF  PULMONARY   TUBERCULOSIS 

The  endemic  diseases  of  childhood,  measles,  whooping-cough,  scarlet 
fever,  etc.,  produce  anergy,  or  lowered  reactive  powers  (see  p.  95) 
to  tuberculosis.  They  are  therefore  to  be  guarded  against  these 
diseases.  Many  a  child,  doing  well  despite  tracheobronchial  adenitis, 
succumbs  to  bronchopneumonia  complicating  measles  or  whooping- 
cough.  It  is  very  difficult  to  carry  out  prophylaxis  against  these 
endemic  diseases  in  children  living  in  the  tenements  of  large  cities; 
and  in  those  who  attend  school  in  any  part  of  a  city,  where  there  are 
so  many  "carriers."  And  we  cannot  isolate  a  child  from  intercourse 
with  other  children  for  obvious  reasons.  This  is  a  fact  which  is  often 
not  considered  in  this  connection  by  those  eager  to  do  something 
along  these  lines.  If  after  all  efforts  at  prevention  of  complicating 
diseases  have  failed,  and  the  child  does  develop  one  of  them,  the  treat- 
ment should  be  very  careful,  and  during  convalescence  the  patient 
should  be  sent  to  the  country  for  a  month  or  so. 

But  infants  can  be  shielded  against  infection  with  measles,  whooping- 
cough,  etc.,  because  they  are  always  in  the  immediate  care  of  the 
mother.  Infants  known  to  have  been  infected  with  tuberculosis  should 
be  kept  away  from  the  proximity  of  other  children  who  are  liable  to 
be  "carriers."  It  is  just  during  infancy  that  measles  and  whooping- 
cough  are  likely  to  do  most  harm  when  attacking  a  subject  harboring 
tuberculous  infection. 

Medicinal  treatment  is  not  indicated  in  most  cases,  excepting  where 
there  is  anemia,  cough,  etc.  These  symptoms  are  best  relieved  by  the 
open-air  treatment.  But  we  may  in  many  cases  assist  or  accelerate 
the  improvement  by  the  administration  of  iron.  The  old  syrupus  ferri 
iodidi  may  be  given  in  doses  of  3  to  5  drops  to  children  three  years  of 
age  and  more  in  proportion  to  older  children.  Iron  tropon  is  another 
good  and  palatable  preparation  for  these  anemic  children.  The  hypo- 
phosphates  do  good  in  many  cases. 

Children  showing  catarrhal  symptoms,  when  not  due  to  inflam- 
matory conditions  of  the  nose  and  throat,  do  well  with  creosote  in  small 
doses;  It  may  be  given  in  doses  of  from  |  to  |  drop  diluted  in  milk. 
Any  of  the  derivatives  of  creosote  may  be  given  in  powder  or  in  syrup 
form.  This  will  often  relieve  a  cough  much  more  effectively  than 
sedative  drugs. 

Specific  treatment  has  been  used  with  less  success  in  children  than 
in  adults.  It  must  be  remembered  that  statistics  of  a  number  of 
children  treated  with  any  method,  including  tuberculin,  are  of  no 
value  if  they  show  that  of  so  many  treated  no  deaths  have  occurred. 
Death  due  to  pulmonary  tuberculosis,  excepting  meningitis,  in  children 
over  two  and  under  fourteen  years,  are  exceedingly  rare.  For  these 
reasons,  orphan  asylums  show  such  splendid  results — children  of 
tuberculous  parentage  do  not  develop  phthisis  while  they  are  in  the 
institutions.  But  in  children  tuberculin  is  not  indicated  because  the 
psychic  factor,  which  is  the  main  curative  factor  in  adults,  is  lacking. 
I  can  see  no  reason  for  giving  tuberculin  to  children. 


TUBERCULOSIS  IN   THE  AGED  611 

Tuberculosis  in  the  Aged.  —  Most  aged  phthisical  patients  are 
emaciated  and  debihtated.  In  many  nourishment  cannot  be  given 
in  plentiful  amount  because  they  lack  teeth  for  mastication,  and  most 
of  them  suffer  from  disturbances  in  the  motility  and  secretions  of 
the  stomach  and  intestines.  They  also  have  arteriosclerosis,  sclerotic 
kidneys,  and  do  not  bear  the  ingestion  of  large  quantities  of  proteids. 
Fats  are  apt  to  induce  diarrhea  more  often  than  in  youthful  subjects. 

These  difficulties  in  the  dietetics  of  aged  consumptives  may  be 
overcome  within  limits  by  first  ordering  the  repair  of  the  teeth.  Then 
they  may  have  a  diet  consisting  mainly  of  milk,  cream,  and  cereals. 
Fish  is  also  well  assimilated  by  aged  persons,  and  they  should  take  it 
when  for  any  reason  meats  are  not  tolerated.  But  as  long  as  the 
condition  of  the  kidneys  is  not  such  as  to  contra-indicate  meats  or 
poultry,  they  may  be  allowed  in  moderate  quantities.  Vegetables 
may  be  given  as  long  as  there  is  no  diarrhea.  While  in  younger  phthis- 
ical patients  alcohol  is  to  be  tabooed,  it  is  different  with  aged  patients. 
If  they  have  been  accustomed  to  alcohol  it  is  not  advisable  to  attempt 
instituting  reforms  at  an  advanced  age.  In  some  cases  alcohol  is  even 
of  distinct  benefit,  if  not  abused. 

Old  patients  do  not  bear  outdoor  life  as  well  as  younger  ones.  The 
same  is  true  of  high  altitude.  They  must  have  warm  rooms  for  living 
and  sleeping.  In  fact,  if  they  can  afford  it  they  should  spend  the 
winter  in  some  southern  region.  The  intense  cold  of  the  winter  has 
a  very  deleterious  effect  on  them  because  of  the  defective  circulation — 
especially  the  peripheral — rigid  arteries,  sclerotic  kidneys,  pulmonary 
emphysema,  etc.,  with  which  many  are  affected.  But  they  need 
fresh  air.  While  they  should  sleep  in  warm  rooms,  the  windows  must 
be  kept  open. 

Cardiac  derangements  are  to  be  carefully  treated  by  rest,  digitalis, 
strophanthus,  etc.  Myocarditis  is,  however,  not  relieved  by  these 
remedies  and,  in  addition  to  rest,  small  doses  of  nitroglycerin,  fre- 
quently repeated,  often  have  a  beneficial  influence.  The  iodides  are 
very  good  in  many  cases  and  should  be  given  in  moderate  doses.  In 
many  patients  the  dyspnea  is  relieved  by  this  remedy  much  more 
effectively  and  lastingly  than  by  anything  else. 

Fever  is  to  be  treated  according  to  the  principles  discussed  in 
Chapter  XXXVIII.  Most  senile  patients  have  no  fever,  but  at  times 
we  encounter  some  with  pyrexia  of  longer  or  shorter  duration.  Those 
in  whom  the  fever  is  mild  and  evanescent  require  rest  in  bed  until  the 
temperature  comes  down  to  normal.  Very  old  persons,  over  sixty 
years  of  age,  do  not  bear  fever  very  well,  and  must  be  given  anti- 
pyretic treatment.  Pyramidon  in  5-grain  doses  may  be  administered 
three  or  four  times  a  day. 

The  cough  and  expectoration  need  no  treatment  as  long  as  they 
are  not  excessive.  Otherwise,  small  doses  of  codein  or  heroin  should 
be  given.  In  many  cases  the  expectoration  is  profuse  and  contains 
numerous  tubercle  bacilli.     It  may  be  greatly  influenced  by  posture 


612       GENERAL   TREATMENT  OF  PULMONARY   TUBERCULOSIS 

as  in  bronchiectasis,  and  postural  treatment  may  be  attempted. 
But  this  is  difficult  with  old  persons,  because  of  their  weakness  and 
debility  they  cannot  withstand  the  vigorous  cough  this  mode  of 
treatment  is  apt  to  induce. 

Tuberculosis  during  the  Menopause. — Tuberculosis  in  women 
during  the  menopause  is  apt  to  be  complicated  by  s^Tuptoms  which 
are  not  seen  in  other  phthisical  patients.  Considering  the  profound 
impression  made  by  the  tuberculous  toxemia  on  the  sexual  sphere 
(see  p.  238),  there  is  no  wonder  that  at  the  "critical  period"  tubercu- 
lous women  should  present  special  symptoms. 

Many  are  more  or  less  obese  despite  the  continued  activity  of  the 
tuberculous  process  in  the  lung.  Dyspnea  is  very  frequent  and  many 
complain  of  cardiac  palpitation.  Hemoptysis  is  very  frequent,  and 
may  replace  the  menstrual  flow,  though  I  should  hesitate  before 
considering  it  vicarious  menstruation.  Copious  hemorrhages  are 
uncommon;  I  am  under  the  impression  that  they  are  less  common 
than  among  others  with  similar  lesions.  But  streaky  sputum  and 
small  hemorrhages  are  very  frequent.  In  addition  there  are  most  of 
the  usual  s\Tiiptoms  of  the  menopause — hot  flushes,  headaches,  etc., 
and  profuse  perspiration.  Combined  with  the  symptoms  of  phthisis 
these  symptoms  of  the  menopause  make  this  class  of  patients  proper 
subjects  for  special  treatment. 

In  addition  to  the  treatment  of  phthisis  outlined  above,  the  special 
symptoms  need  attention.  I  have  had  several  cases  in  which  repeated 
hemoptysis  was  stopped  by  the  administration  of  the  extract  of  the 
ovaries  or  the  corpus  luteum.  Indeed,  most  of  the  annoying  symptoms, 
which  torture  the  unfortunate  woman  more  than  those  caused  by  the 
tuberculous  process,  may  be  relieved  by  the  timely  and  proper  admin- 
istration of  these  remedies.  It  is  also  a  fact  worthy  of  remembering 
that  during  the  climacteric  phthisical  women  do  not  bear  the  admin- 
istration of  tuberculin  very  well;  most  are  apt  to  be  harmed  by 
specific  treatment. 

The  cough  and  insomnia  also  are  best  relieved  by  the  ovarian  sub- 
stance; sedatives  and  hypnotics  often  aggravate  this  condition. 
Though  in  many  cases  bromides  and  valerianates  are  effective. 


CHAPTER  XLI. 
TREATMENT  OF  COMPLICATIONS. 

Pleurisy. — Dry  localized  pleurisy  occurring  during  the  course  of 
phthisis  needs  no  special  treatment,  excepting  to  relieve  the  pain  which 
is  at  times  annoying.  In  mild  cases  external  applications  may  suffice 
to  give  the  patient  comfort.  Any  of  the  belladonna  plasters  or  a  sin- 
apism may  do;  while  some  apply  tincture  of  iodin.  The  writer  finds, 
however,  that  the  administration  of  salicylates  often  relieves  these 
pleural  pains  much  better  than  anything  else.  Aspirin,  in  doses  of 
from  5  to  10  grains  three  or  four  times  a  day,  may  be  given  in  cases  in 
which  sodium  salicylate  is  liable  to  derange  the  stomach. 

In  acute  cases  of  pleurisy  the  pain  may  be  very  severe  during  the 
first  few  days  before  the  effusion  appears  and  may  necessitate  the 
administration  of  morphin,  i  to  J  grain  hypodermically.  In  most 
cases  it  is  not  necessary  to  repeat  it,  but  it  is  better  to  strap  the  chest 
with  adhesive  plaster.  As  soon  as  the  effusion  appears  the  acute  pain 
usually  ceases. 

The  patient  is  to  be  kept  in  bed  as  long  as  the  fever  lasts.  But 
during  the  later  stages  he  may  be  permitted  to  take  mild  exercises. 
The  diet  is  to  be  given  in  accordance  with  the  temperature  and  the 
tuberculous  process  in  the  lungs. 

It  is  not  advisable  to  make  any  efforts  to  hasten  absorption  of  the 
fluid  in  cases  of  tuberculosis.  The  fluid  may  be  serving  a  useful  pur- 
pose by  compressing  the  lung  and  facilitating  the  healing  of  the  lesion 
in  the  same  manner  as  an  artificial  pneumothorax  does.  On  this 
principle  effusions  may  be  permitted  to  remain  for  months.  But  in 
case  the  effusion  causes  severe  dyspnea,  cyanosis,  cardiac  weakness, 
insomnia  and  other  urgent  symptoms,  it  should  be  aspirated  at  least 
partially.  But  even  then  aspiration  should  be  left  as  a  last  resort 
because  speedy  withdrawal  of  the  fluid  and  rapid  expansion  of  the 
lung  may  awaken  the  tuberculous  process  into  acute  activity.  The 
writer  has  observed  this  to  happen  in  several  cases. 

It  is  best  to  first  try  autoserotherapy.  Five  to  10  c.c.  of  the  fluid  is 
withdrawn  with  an  aspirating  syringe  and  reinjected  into  the  subcuta- 
neous tissue.  A  good  way  is  not  to  remove  the  needle  after  the  syringe 
is  filled  with  the  fluid,  but  while  withdrawing  it,  when  its  point  reaches 
the  subcutaneous  tissue,  to  turn  it  parallel  to  the  surface  of  the  chest 
and  to  inject  the  fluid  right  then  and  there,  as  was  described  by  the 
writer^  elsewhere.     This  can  be  done  several  times  on  alternate  days. 

1  Jour.  Amer.  Med.  Assn.,  1913,  Ix,  962. 


614  TREATMENT  OF  COMPLICATIONS 

In  most  cases  there  will  be  noted  an  increase  in  diuresis  and  the  level 
of  the  fluid  begins  to  sink,  so  that  within  a  couple  of  weeks  it  may  be 
absorbed  altogether. 

In  cases  in  which  autoserotherapy  is  of  no  avail  and  the  general  con- 
dition of  the  patient  demands  removal  of  the  effusion,  aspiration  should 
be  done.  It  is  advisable  not  to  remove  all  the  fluid  at  one  sitting,  but 
to  do  it  on  alternate  days,  each  time  withdrawing  a  part.  In  many 
cases  the  pleura  refills  soon  after  tapping,  and  it  is  necessary  to  assist 
the  absorption  by  giving  a  salt-free  diet,  and  to  reduce  the  amount  of 
fluid  ingested  by  the  patient.  Diuretin  may  be  of  assistance  by 
increasing  diuresis.  But  other  drugs,  reputed  as  assisting  absorption 
of  plem-al  effusions,  as  the  iodides,  are  impotent  in  this  regard. 
Emptymg  the  bowels  daily  with  salines,  if  there  are  no  contra-indica- 
tions,  may  assist  in  the  absorption  of  the  fluid. 

Empyema. — The  treatment  of  purulent  effusion  during  the  course 
of  phthisis  is  very  unsatisfactory.  Some  authors  have  stated  that 
when  the  pus  shows  streptococci  and  staphylococci,  the  prognosis  is 
better  and  resection  of  one  or  tWo  ribs  may  bring  about  a  cure,  while 
in  cases  in  which  the  pus  shows  the  presence  of  tubercle  bacilli,  opera- 
tion is  futile.  In  the  experience  of  the  writer  there  was  no  difference 
from  this  viewpoint.  On  very  rare  occasions  we  meet  with  a  case  in 
which  several  aspirations  of  the  pus  cures  the  empyema.  Similarly 
the  writer  has  had  2  cases  of  localized  and  encapsulated  empyemata 
which  broke  through  bronchi,  the  pus  was  expectorated  and  the 
patients  recovered.  In  the  vast  majority  of  cases  we  keep  on  with- 
drawing larger  or  smaller  quantities  of  pus,  but  the  chest  fills  up  again 
in  a  short  time.  In  some  cases  fistulse  form  along  the  track  of  the 
needle,  discharging  pus  externally. 

The  results  of  operations  for  empyema  complicating  phthisis  are 
unsatisfactory.  A  simple  incision  for  the  evacuation  of  the  pus  is 
nearly  always  followed  by  a  fistula  necessitating  the  patient  to  go 
around  with  a  foul  smelling  bandage  for  the  rest  of  his  life.  For  this 
reason  most  physicians  are  at  present  satisfied  with  the  aspiration 
of  the  pus  repeated  according  to  indications. 

Whether  treated  by  operation  or  thoracocentesis,  the  fever  usually 
keeps  up,  dropping  after  the  removal  of  part  of  the  pus,  but  rising 
again  within  a  few  days.  Emaciation,  nightsweats,  anorexia,  diarrhea, 
etc.,  keep  on;  amyloid  degeneration  of  the  viscera,  notably  the  liver 
spleen,  kidneys,  and  intestines,  develops  and  the  patient  sooner  or 
later  succumbs  to  exhaustion. 

The  suggestion  of  some  authors  that  after  removing  the  pus  nitro- 
gen should  be  inflated  into  the  pleura  has  been  tried  by  the  writer, 
not  found  to  offer  any  advantages,  and  was  abandoned. 

Spontaneous  Pneumothorax.— In  the  treatment  of  this  complication 
we  must  consider  whether  this  accident  may  not  ultimately  turn 
out  of  use  by  collapsing  the  lung  and  thus  facilitating  the  healing 
process  as  the  artificial  variety  often  does.    This  is  exceedingly  rare; 


SPONTANEOUS  PNEUMOTHORAX  615 

still  now  and  then  we  meet  with  a  case  in  which  a  spontaneous  pneu- 
mothorax is  followed  by  improvement  in  the  symptoms  of  the  original 
disease. 

The  acute  onset  with  shock,  pain,  dyspnea,  etc.,  demands  active 
treatment.  The  indications  are  clear:  The  patient  is  to  be  relieved 
of  the  urgent  and  menacing  symptoms,  his  heart  is  to  be  stimulated, 
etc.,  which  is  best  done  by  a  hypodermic  injection  of  morphin.  But 
if  the  patient  is  not  calmed,  and  the  dyspnea  is  urgent,  thoracocentesis 
is  to  be  performed.  This  is  often  the  only  means  at  our  command  to 
relieve  the  extreme  and  agonizing  dyspnea.  Tapping  the  air  in  the 
affected  pleural  cavity  gives  prompt  relief,  though  unfortunately  only 
of  short  duration  in  most  cases.  Plunging  a  hypodermic  needle  into 
the  affected  side  is  sufficient,  because  the  expiratory  pressure  within 
the  pleura  is  greater  than  that  of  the  external  atmosphere.  It  is  good 
to  attach  a  rubber  tube  to  the  needle  by  one  end,  while  the  other  is 
placed  in  a  pail  of  water,  thus  forming  a  water  valve  which  permits 
the  free  exit  of  the  air  from  the  chest,  but  prevents  its  return. 

If  the  relief  thus  obtained  is  only  transitory,  the  operation  is 
repeated;  in  some  cases  it  may  be  necessary  to  repeat  the  tapping 
four,  five,  or  even  seven  times  during  the  first  day.  Some  have  tried 
to  obviate  this  by  inserting  a  cannula  and  leaving  it  in  the  chest 
wall  for  several  hours  or  days;  the  rubber  tube  all  the  time  in  the 
water.  But  I  have  found  it  very  difficult  to  retain  the  needle  in 
place  and  to  keep  it  aseptic.  For  this  reason  I  prefer  to  make  several 
punctures  as  the  urgency  of  the  symptoms  demands. 

Many  theoretical  objections  have  been  raised  against  tapping  the 
chest  in  these  cases.  But  one  has  only  to  witness  a  case  in  which  the 
agonizing  pain  and  air  hunger  are  promptly  relieved  by  tapping,  to 
appreciate  that  this  is  the  only  measure  which  gives  relief.  As  in 
urgent  cases  of  any  kind,  theoretical  considerations  are  left  till  the 
menacing  symptoms  are  under  control.  In  fact,  after  one  tapping  the 
patient  begs  for  another  when  the  dyspnea  returns. 

We  meet  with  cases  in  which  the  embarrassment  of  the  circulation 
and  respiration  continues  in  spite  of  repeated  tappings,  and  the  prog- 
nosis is  gloomy.  The  causes  are  not  primarily  mechanical,  but  physio- 
logical. The  opposite  lung  is  congested  and  the  circulation  is  thereby 
more  embarrassed  than  by  the  displacement  of  the  mediastinum.  In 
these  cases  we  may  try  oxygen  inhalation  and  cupping  all  over  the 
posterior  aspect  of  the  chest.  Some  use  wet  cups  or  venesection  to 
relieve  the  right  ventricle  which  is  becoming  paralyzed  from  extreme 
overdistention.  "I  have  no  doubt,"  says  West,  "that  life  might  be 
sometimes  saved  by  timely  venesection  and  it  is  certain  that  bleeding 
is  not  as  much  employed  in  these  urgent  cases  as  it  ought  to  be." 

The  heart  section  is  to  be  sustained  by  large  doses  of  strychnia, 
digitalis,  spartein,  or  camphor. 

In  milder  cases,  especially  those  in  which  the  pneumothorax  is  only 
partial  and  the  symptoms  are  not  so  urgent,  the  treatment  is  less 


616  TREATMENT  OF  COMPLICATIONS 

vigorous.  The  dyspnea,  pain,  and  distress  are  usually  controlled  by 
a  dose  of  morphine  hypodermically,  and  within  a  day  or  two  the 
patient  feels  quite  comfortable. 

The  after-treatment,  if  the  patient  survives  three  or  four  days,  is 
that  of  the  underlying  tuberculous  process  in  the  lungs.  Inasmuch 
as  the  pneumothorax  with  its  sudden  onset  and  agonizing  symptoms 
often  leaves  the  patient  in  a  debilitated  condition,  rest  and  proper 
feeding  are  to  be  enforced.  In  rare  cases  the  pneumothorax,  acute 
and  menacing  as  it  was  at  the  onset,  turns  out  to  be  "providential," 
as  some  French  authors  say.  The  collapsed  lung  is  given  an  oppor- 
tunity to  heal  and  recovery  may  take  place  ultimately.  Some 
recommend  that  in  such  cases  the  pneumothorax  should  be  conthiued 
by  injections  of  nitrogen  in  the  approved  manner. 

After  the  menacing  symptoms  have  abated  the  patient,  regaining 
his  strength  and  composure,  provided  he  has  no  fever,  may  be  per- 
mitted to  leave  his  bed  and  take  mild  walking  exercises.  We  know 
now  from  experience  with  artificial  pneumothorax  that  one  can  do 
considerable  exercise  or  even  work  when  one  pleural  cavity  is  filled 
with  air  and  the  lung  collapsed.  But  a  spontaneous  pneumothorax 
is  not  always  closed  and  exercises  may  cause  some  of  the  morbid 
secretions  to  enter  the  pleura  through  the  fistula  and  cause  pyothorax. 

Hydropneumothorax. — The  treatment  of  effusion  into  a  pleural 
cavity  filled  with  air  is  conservative,  just  as  that  of  pneumothorax. 
The  fluid  is  absorbed  sooner  or  later  spontaneously.  We  now  have 
experience  with  this  condition  in  cases  with  artificial  pneumothorax. 
As  long  as  there  is  no  fever  or  dyspnea  the  patient  may  be  allowed 
considerable  exercise.  But  in  case  the  intrathoracic  pressure  becomes 
high  and  produces  dyspnea  when  the  patient  is  at  rest,  the  pressure 
must  be  reduced.  This  can  be  done  by  withdrawing  some  of  the  air 
or  fluid.  The  latter  is  the  best.  With  an  aspirating  apparatus  a 
part  of  the  exudate  is  withdrawn.  In  many  cases  the  operation  has 
to  be  repeated.  In  favorable  cases  this  withdrawal  stimulates  the 
absorption  of  the  rest  of  the  fluid.  In  several  cases  I  have  had  good 
results  with  autoserotherapy  (p.  613). 

Pyopneumothorax. — The  treatment  of  this  complication  is  very 
unsatisfactory.  Operative  interference  has  not  given  encouraging 
results.  At  best,  a  fistula  is  left  in  the  chest  which  discharges  pus 
indefinitely.  The  ultimate  result  is  worse  than  when  only  tapping  of 
the  pus  is  resorted  to.  The  indications,  therefore,  are  to  aspirate  the 
pus  at  frequent  intervals  with  a  view  of  keeping  the  patient  afebrile 
as  far  as  possible.  The  bacteriological  findings  have  no  influence  on 
the  prognosis  and  treatment,  as  has  already-  been  stated  when  speaking 
of  empyema  complicating  phthisis. 

Laryngeal  Tuberculosis. — Many  cases  of  tuberculous  laryngitis 
show  a  strong  tendency  to  spontaneous  cure,  especially  in  patients 
whose  lung  lesion  also  manifests  a  tendency  to  improvement.  In  fact 
the  progress  of  the  lesion  in  the  larynx  goes  hand  in  hand  with  the 


LARYNGEAL   TUBERCULOSIS  617 

progress  of  the  lung  lesion,  though  the  physical  signs  of  the  latter  are 
apt  to  be  obscured  by  the  former.  This  is  clearly  seen  in  cases  in  which 
the  induction  of  a  therapeutic  pneumothorax  is  effective  in  curing  the 
patient.  If  there  has  been  a  laryngeal  lesion  it  often  shares  in  the 
general  improvement  of  the  patient. 

In  my  experience  local  treatment  is  not  often  effective  in  enhancing 
cicatrization  of  laryngeal  lesions.  When  carried  out  vigorously,  it  is 
apt  to  do  harm.  The  application  of  local  escharotics  and  cauteriza- 
tion has  been  harmful  in  the  long  run,  or  of  no  benefit  in  the  vast 
majority  of  my  cases.  As  has  been  pointed  out  by  St.  Clair  Thomson,^ 
lactic  acid,  which  is  the  favorite  drug  used  by  laryngologists,  is 
unavailing  except  in  strengths  of  50  per  cent,  or  more.  Hence  sprays 
of  2  per  cent,  are  nothing  but  irritating.  Frequent  applications  are- 
also  irrational,  the  object  being  to  produce  an  eschar  which  does  not 
separate  for  one  to  three  weeks.  When  the  slough  is  detached  a 
healing  ulcer  is  exposed;  but  there  are  generally  deeper  deposits 
requiring  a  repetition  of  the  cauterizing  process,  so  that  four  to  twelve 
applications  may  have  to  be  spread  over  as  many  months.  The  use 
of  a  20  to  25  per  cent,  solution  of  argyrol,  or  a  2  per  cent,  solution  of 
methelene  blue  for  local  application,  as  advised  by  Fetterolf,  is  less 
likely  to  be  painful  or  harmful.  Where  the  mucous  membrane  is 
unbroken  no  local  application  of  drugs  does  any  good. 

In  a  few  cases  I  have  seen  excellent  results  when  the  patient  ceased 
talking  altogether,  thus  affording  perfect  rest  to  the  larynx.  But  it 
must  be  done  thoroughly.  The  patient  should  have  a  pad  and  pencil 
and  carry  on  all  conversation  in  writing.  In  two  cases,  both  women, 
in  whom  this  treatment  was  carried  out  perfectly,  the  laryngeal  lesion 
healed.  There  are,  however,  few  patients  who  want  to  submit  to  this 
treatment  for  a  long  time.  In  patients  with  advanced  and  active  lesions 
in  the  lungs,  there  is  no  reason  for  trying  it,  because  they  are  doomed 
anyway. 

As  has  been  shown  by  Fetterolf,^  there  is  one  form  of  the  disease 
in  which  unlimited  use  of  the  voice  is  advisable,  this  being  the  variety 
in  which  the  vocal  cords  are  the  only  parts  of  the  larynx  involved. 
This  is  commonly  called  the  ''chorditic"  form,  the  cords  appearing 
slightly  congested  and  having  on  their  upper,  and  to  a  slight  extent 
on  their  mesial  aspect  a  number  of  reddish  granular  growths.  These 
are  possibly  sometimes  submucous  tubercles,  but  more  frequently 
are  distended  mucous  glands  with  their  duct  orifices  occluded.  Vocal 
exercise  aids  in  clearing  up  the  condition,  and  it  is  in  this  form  that 
improvement  of  the  voice  so  frequently  follows  an  acute  coryza. 

In  all  cases  with  dysphagia  palliative  treatment  must  be  applied. 
We  may  try  to  obtain  relief  by  laryngeal  insufflations  of  3  to  5  grains 
of  orthoform  or  anesthesin.  It  is  only  effective  when  there  is  ulceration 
and  the  powder  remains  on  the  ulcer.    If  given  about  one  hour  before 

1  Diseases  of  the  Nose  and  Throat,  New  York,  1912,  p.  606. 

2  Hare's  Modern  Treatment,  Philadelphia,  1911,  ii,  402. 


618 


TREATMENT  OF  COMPLICATIONS 


the  main  meal  the  patient  may  be  comfortable  for  a  whole  day. 
following  formulse  may  also  be  used: 


The 


IJ — Orthoformi gr.  xxx 

lodoformi gr.  xxx 

Mentholi gr.  vj 

M.     S. — Insufflate  a  few  grains  one  hour  before  meals. 

I^ — Cocaine  hydrochloridi gr.  x 

Morphinse  hydrochloridi gr.  ij 

Mentholis gr.  xv 

lodoformi gij 

Acidi  borici 5ij 

M.     S. — Insufflate  a  few  grains  one  hour  before  meals. 


2.0 
2.0 
0.4 


0.7 
0.1 
1.0 
8.0 
8.0 


The  application  of  these  powders  is  to  be  made  with  special  insuffla- 
tors. They  are  designed  so  that  the  spray  goes  vertically  downward, 
not  backward  into  the  pharynx. 


Hifoid  bojte  - 
SupXanfn^eal  /lerm'^^ 
7h^ro-^i/oid  Tmiscle  -  - 
LoTyn^eal  artery ---■ 
Omohyoid  muscle- 

Sternohyoid  muscle - 
Carotid  artery 


Fig.  90. — The  thyrohyoid  region 


In  some  cases  the  dysphagia  is  severe  and  not  at  all  influenced  by 
the  application  of  remedies  locally.  Injections  of  alcohol  into  the 
superior  laryngeal  nerve  may  then  be  tried.  Relief  from  pain  may  be 
obtained  lasting  several  weeks.  Rudolf  Hoffmann  was  the  first  to 
suggest  this  mode  of  treatment.  The  technic  of  the  injection  is  thus 
given  by  J.  Dundas  Grant.^ 

Place  the  patient  in  a  horizontal  position  and,  with  the  thumb  of 
the  left  hand,  press  the  sound  side  of  the  larynx  toward  the  middle 
line  so  that  the  affected  half  projects  distinctly;  the  other  fingers  of 
the  hand  lie  on  this.    The  index  finger  enters  the  space  between  the 


1  Lancet,  1910,  i,  17.54. 


LARYNGEAL  TUBERCULOSIS 


619 


thyroid  cartilage  and  the  hyoid  bone  from  without  until  the  patient 
announces  that  a  painful  spots  had  been  reached.  With  a  little 
practice  one  arrives  at  it  at  the  first  go-off,  when  one  has  become 
familiar  with  the  topographical  relations.  Now  the  nail  of  the  index 
finger  is  placed  on  the  skin  (which  has  been  previously  disinfected) 
in  such  a  way  that  the  point  of  entrance  for  the  needle  lies  opposite 
its  middle.  The  needle  is  pushed  in  for  about  1.5  cm.  and  this  distance 
is  marked  off  on  the  needle  perpendicular  to  the  surface  of  the  body. 
According  to  the  thickness  of  the  subcutaneous  layer  of  fat,  the 
perforation  has  to  be  more  or  less  dteep.  The  needle  is  then  carefully 
moved  so  as  to  seek  a  spot  at  which  the  patient  states  that  he  feels 
pain  in  the  ear.    The  syringe  filled  with  85  per  cent,  alcohol  warmed  to 


Ifyoid  bo?ie-- 
Thi/roid  cartilagre. 


Cricoid  cartilage  ^  -  \      \ 


Fig.  91. — Space  where  to  insert  the  needle  for  producing  anesthesia  of  the  superior 
laryngeal  nerve.     (Celles.) 


the  temperature  of  45°  C.  (113°  F.)  is  screwed  on  to  the  handle  and 
the  piston  is  then  slowly  pressed  down.  The  patient  now  feels  pain 
in  the  ear,  the  passing  off  of  which  he  indicates  by  raising  his  hand. 
During  the  operation  he  has  to  avoid  both  swallowing  and  speaking; 
if,  however,  he  makes  a  movement  of  swallowing  we  must  follow  the 
movement  of  the  syringe  with  a  light  touch.  The  injection  is  kept  up 
until  no  further  pain  occurs  in  the  ear;  then  the  needle  is  removed  and 
collodion  or  sticking  plaster  is  placed  on  the  spot  of  the  injection 
without  pressure.  The  needle  employed  should  be  one  with  a  point 
bevelled  off  much  more  obtusely  than  in  an  ordinary  hypodermic 
needle,  so  as  to  avoid  the  risk  of  puncturing  a  vessel. 


620  TREATMENT  OF  COMPLICATIONS 

I  have  tried  this  method  in  many  cases  and  obtained  relief  for  the 
patient  in  about  50  per  cent.  Failures  are  due  to  missing  the  nerve, 
which  is  unavoidable  in  many  cases. 

There  are  cases  in  which  all  the  above  fail  to  relieve  the  sufferer 
and  all  we  can  do  is  to  give  large  doses  of  anodyne  drugs.  In  some  we 
may  obtain  relief  by  helping  the  patient  in  the  following  manner  while 
he  eats:  A  trained  person  stands  behind  the  patient  and  makes  firm 
and  even  pressure  at  the  angle  of  each  jaw  at  the  moment  of  swallow- 
ing. Another  way  is  known  as  Wolfenden's  position:  The  patient 
lies  prone  over  the  bed  with  the  face  over  the  end  and  sucks  the 
nourishment  through  a  glass  tube  from  a  cup  on  the  floor.  These 
maneuvres  seem  cumbersome,  to  say  the  least,  but  when  having  a 
under  our  care  a  patient  who  cannot  swallow  even  water  without 
severe  pains  in  the  throat,  we  are  ready  to  try  anything. 

There  remains  yet  to  mention  the  various  operations  of  curettage 
and  cautery  which  laryngologists  perform  in  these  cases.  Some 
employ  direct  laryngoscopy  while  operating,  but  this  is  not  only  vio- 
lent, but  the  results  have  been  disastrous  in  all  the  cases  that  have 
been  done  for  me.  In  advising  operation  to  a  patient  of  this  class  we 
must  first  ascertain  the  general  and  the  local  condition  of  the  lungs. 
In  case  the  prognosis  is  poor  from  the  generaUcondition,  there  is  no 
reason  for  operating.  I  always  object  to  operations  in  febrile  and 
cachectic  patients. 


INDEX  OF  AUTHORS. 


Ad  AMI,  54,  131 

Adelung,  von,  573,  577,  592,  593 

Albrecht,  80 

Aldrich,  420 

Alexander,  44 

Allard,  89 

Allbutt,  86,  89,  506 

Amenomiya,  313 

Ancell,  53,  203 

Anders,  92,  186,  187,  192,  193 

Anderson,  226 

Anderson,  John  F.,  49 

Aretaeus,  244,  519 

Arloing,  29,  36 

Arnsperger,  297 

Aschoff,  129 

Atwater,  520 

Auch,  81 

Aufrecht,  45,  110,  253,  264 

Ayer,  135 

Bacmeister,   43,   45,   84,   87,    104,    128, 

135,  225,  324 
Baer,  600 
Balboni,  570,  577 
Baldwin,  32,  38,  82,  113,  452,  540 
Ballenger,  409 
Bamberger,  228 

Bandelier,  282,  324,  365,  435,  543 
Bang,  113 
Barbier,  228,  253 
Bard,  355,  365,  403 
Bardswell,  169,  516,  523 
Barnes,  240,  532 
Barot,  386 

Bartel,  41,  44,  117,  498 
Bartlett,  49,  55,  111 
Barwell,  408,  410 
Barwise,  99 

Baumgarten,  45,  50,  79,  80,  114,  122 
Bayle,  302,  355,  412 
Beale,  176 
Beck,  323 
Beddoe,  242 
Behrend,  320 

Behring,  42,  49,  105,  106,  117,  369 
Beitzke,  36,  45,  47,  129,  226 
Bender,  417 
Benedict,  482 
Bennett,  203 
Bergel,  498 
Bernard,  597 
Bernheim,  448 


Bertillon,  66 

Besredka,  324 

Bessesen,  245 

Bezangon,  215,  253,  278,  305,  332 

Bibb,  292,  296 

Biggs,  66,  475 

Binet,  83 

Birch-Hirschfeld,  45,  58,  86,  92 

Bisaillon,  600 

Blake,  382 

Blomel,  543 

Blum,  229 

Boardman,  160,  292,  296 

Bodington,  480 

Bohland,  221 

Bonney,  253,  412,  561 

Borschke,  413 

Bosanquet,  89 

Boston,  317,  366 

Bowditch,  89 

Bowlby,  391 

Bram,  226 

Brandenburg,  408 

Brauer,  569,  570 

Bray,  167,  168,  173 

Brehmer,  82,  480 

Brieger,  205 

Bronfenberenner,  324 

Brooks,  Harlow,  97,  113 

Brown,    Lawrason,    92,    211,    253,    259, 

345,    441,    478,    481,    495,    509,    515, 

546 
Brown,  William  Garet,  453 
Bruce,  356,  424 
Bruckner,  320 
Brtigelmann,  90 
Brunon,  110 
Brunton,  Lauder,  506 
Budd,  203 

Bullock,  412,  493,  589 
Burkhardt,  54,  55,  58 
Burns,  92,  93,  193,  211 
Bushnell,  287 


Cabot,  Richard,  C,  287 

Cahnette,  47,  60,  84,  106,  369,  324 

Capps,  234 

Carpi,  592 

Carrington,  Thomas  S.,  481,  485 

Carson,  James,  568 

Castaigne,  403 

Cattermole,  60- 


622 


INDEX  OF  AUTHORS 


Cavagnis,  80 

CeUes,  614 

Chalier,  81 

Chamberland,  81 

Chambers,  L.  K.,  53 

Chantemesse,  140,  418 

Chapin,  Charles  V.,  40,  42,  48,  51 

Chapman,  169,  516,  523 

Chausse,  40 

Childs,  296,  298 

Chittenden,  519 

Clark,  Andrew,  139,  195,  255,  305,  435 

Clark,  James,  203 

Clouston,  235 

Cohen,  410 

Cohen,  SoUs,  M.,  226 

Cohn,  295 

CoUis,  99 

Combe,  519 

Condie,  186 

Copeland,  94 

Cornet,  21,  39,  40,  52,  58,  98,  184 

Cotton,  20,  40,  48 

Comicilman,  49 

Com-coux,  140 

CouiTQont,  597 

Cowan,  407 

Craig,  224 

Croftan,  83 

Cruice,  412,  421 

Cummings,  481,  484,  485 

Cmnmins,  62 

Cursham,  418 

Czemy,  378 

DaCosta,  J.  M.,  264 

Da  Costa,  John  Chalmers,  385 

Da  Gradi,  594 

Damman,  36 

Daremberg,  170,  173,  515,  522 

Dastre,  560 

Davis,  D.  J.,  26 

Day,  27 

Debains,  324,  432 

Debove,  514 

Dehn,  297 

De  Jong,  29 

Delafield,  133 

Dellile  Armade,  387 

Delpeuch,  242 

De  Renzi,  531 

Destree,  232 

Dettweiler,  505.  517  549 

Deulafoy,  90 

Doane,  20 

Dobell,  203 

Dobrovici,  443,  546 

Doerr,  26 

Dold,  226 

Dorset,  19 

Dowdell,  418 

Doyen,  291 

Duckworth,  Dyce,  434 

Dunham,  292,  ^296 

Dworetzky,  408 


Eden,  49 
Einhorn,  205 
Elderton,  111 
Engel,  235 
d'Espine,  386 

Ewart,  WiUiam,  132,  133,  134,  138,  287, 
343,  385 

Fagge,  92 

FaginoU,  589,  590 

Fenwick,  414 

Fen^dck,  W.  Soltau,   154,  203,  262,  282 

Fetterolf,  467,  617 

Fildes,  324 

Finkler,  327 

Fisac,  99 

Fischer,  510,  519 

Fleissinger,  498 

FHck,  560 

Flint,  Austin,  201,  263,  339 

Floresco,  560 

Florschiitz,  111 

Floyd,  570,  574,  577,  589,  592 

Fltigge,  39,  41,  42,  482 

Fochi,  559 

Folin,  519 

Fordyce,  John  A.,  118 

Forlanini,  568,  570,  576 

Forster,  344 

Forsyth,  535 

Fowler,  J.  Ivingston,  76,  131,  540,  544 

Fox,  WUson,  150,  186,  200 

Fra^kel,  547 

Frankel,  Albert,  327 

Frankel  Lee  K.,  66 

Franz,  323 

Eraser,  35,  115 

Fraser,  Thompson,  493 

Freudenthal,  W.,  410,  483 

Freund,  84,  85,  104 

Frey,  560 

Friedmann,  F.  F.,  25,  79,  80,  443 

Friedreich,  339 

Fulton,  John  W.,  74 

Funk,  Ehner  H.,  186 

Gabbet,  159 
Gaffky,  48 
Galecki,  272 
Galen,  201.  244,  249 
Ganghofner,  320 
Garb,  99 
Gartner,  80 
Gassmann,  206 
Gaube,  S3 
Geipe,  81 
Geisbock,  222 
Gerhardt,  197,  339,  560 
Ghon,  48,  128,  139,  372 
Gibson,  387 
Gignaux,  195 
Gilbert,  225,  344,  498 
Gilliland,  292,  296 
Gimbert,  240 
Glaister,  66,  67 


INDEX  OF  AUTHORS 


623 


Glover,  Edward  G.,  367 

Goethe,  200 

Goldscheider,  253,  270,  271,  275 

Gorel,  195 

Goring,  111 

Graetz,  570 

Grancher,  203,  253,  276,  279,  385,  535 

Grant,  618 

Grasser,  100 

Grawitz,  224 

Gray,  593 

Griesinger,  93    ^ 

Griffith,  35 

Grivot,  619 

Grocco,  589 

Grysez,  48,  60 

Gueneau  de  Mussy,  222 

Guinon,  374 

Guyenet,  412 

Haldane,  99,  482 

Hall,  D.  C,  487 

Hall,  F.  de  Haviland,  195 

Halter  99 

Hamburger,  F.,  31,  48,  60,  105,  320,  374 

378,  392 
Hamman,  570,  592,  323 
Harbitz,  44,  54,  55 
Hare,  134 
Harras,  84 

Harrington,  T.  F.,  232,  407 
Harris,  176 
Hart,  82,  87,  104 
Hartley,  413 

Hansemann,  103,  302,  542 
Haupt,  111 
Haushalter,  418 
Haven,  L.  C,  225,  498 
Hawes,  101,  102,  287,  408 
Hayem,  205 
Head,  G.  D.,  231 
Head,  Henry,  233 
Heerokles,  418 
Heim,  183,  323 
Heller,  226,  417 
Helmers,  531 
Henke,  141 
Hermann,  159 
Herter,  519 
Heublein,  389 
Heymann,  42 
Hill,  Leonard,  482 
Hillenberg,  61 
Hinsdale,  Guy,  497,  502 
Hippocrates,  52,  214,  239,  242,  244 
Hirsch,  63 
Hirtz,  220,  419 
His,  86,  254,  255 
Hoffman,  F.  L.,  71,  97,  98 
Hoffmann,  F.  A.,  90 
Hoffmann,  Rudolph,  618 
Hoist,  294 

Holt,  38,  159,  369,  374 
Honeij,  387 
Howell,  387 


Hrdlicka,  61 
Humphrey,  -420 
Hutchinson,  203,  205 
Hutchinson,  Woods,  61,  114,  245 

Inman,  34,  475 
Iscovesco,  535 

Jaccound,  535 
Jackh,  80 
Jacob,  237 
Jacobi,  A.,  462,  526 
Jacobson,  237 
Jacoby,  Martin,  163 
V.  Jaksch,  164 
James,  T.  L.,  498 
Jani,  80 
Janowski,  204 
Jeannin,  213 
Jessen,  234 
Jones,  Noble  W.,  44 
Jordan,  293 
Joseph,  163 
Jupille,  324,  432 

Kagan,  226 

Kast,  126,  130 

Keith,  Arthur,  87 

Kellogg,  518,  519 

Kendal,  27 

Kennerknecht,  226 

Kessel,  226 

Kidd,  Percy,  92,  408,  412 

King,  112,  441,  470,  508,  516 

Kitasato,  49 

Kjer-Petersen,  225 

Klebs,  31,  365,  543 

Klemperer,  Felix,  50,  114,  205,  589 

Klenke,  21 

Klimmer,  241 

Knight,  500 

Knopf,  465 

Knott,  60 

Koch,  R.,  17,  22,  28,  30,  73,  80,  118 

Kohler,  F.,  241 

Kohlisch,  39,  40 

Koniger,  89 

Kophk,  389 

Koranyi,  384 

Koslow,  226 

Koster,  89 

Krause,  106,  241,  295 

Kreuscher,  593 

Kreutzfuchs,  293 

Kronig,  253,  264,  269,  326 

Ivrumwiede,  24,  28,  37 

Kuban,  98 

Klilbs,  100,  328 

Kurashige,  226 

Kiiss,  127,  325,  526 

Kuthy,  26,  82,  155,  157,  184,  289 

Laennec,  53,  121,  301,  341,  423 
Landis,  204,  338,  457 


624 


INDEX  OF  AUTHORS 


Landouzy,  89 

Latham,  Arthui-,  462,  506 

Lauritz,  206 

Learning,  284 

Lebert,  201,  412 

Lee,  F.  S.,  482 

Lees,  253,  313 

Lehmann,  81 

Lemke,  593,  596 

Lemoine,  434 

Leon-Kindberg,  228 

Leredde,  325 

Lesague,  204,  420 

Lesne,  418 

Letulle,  60,  237,  240 

Leube,  509 

Leudet,  345 

Levanditi,  118 

Levene,  31 

Levy,  111,  117,  222 

Leyden,  417 

Liebermeister,  226,  418 

Limbeck,  224 

Locke,  218 

Longstrath,  233 

Loomis,  305 

Lord,  Fred.  T.,  200 

Louis,  91,  150,  206,  402,  412,  418 

Lubarsch,  45,  49,  54,  55,  57 

Luschka,  154,  255,  256 

Lyon,  J.  A.,  586,  592 

McCrea,  54,  131 

Mcintosh,  324 

McLean,  475 

McNeil,  li'5 

McSweeney,  Edward  S.,  506,  511 

Macht,  173,  174,  196,  559,  560 

Mackenzie,  Hector,  542 

Mackenzie,  James,  233,  234 

Mackenzie,  Morell,  408 

MacWhinnie,  486,  487 

Maffucci,  21,  22,  80 

Magnus- Alsleben,  190 

Mahler,  20 

Mallory,  49 

Manning,  60 

Manoukhine,  324,  433 

Mantoux,  59,  182 

Marfan,  112,  205 

Marie,  498 

Marquard,  241 

Martius,  79,  115 

Massol,  342 

Mathieu,  443,  546 

Matson,  Ralph  C,  570,  600 

Matson,  Ray  W.,  299 

Mayer,  435 

Mayo,  112 

Mays,  Thomas  J.,  423 

Meader,  18 

Melchior,  206 

Mendel,  519 

Metchnikoff,  43,  61,  106,  122,  519 

Metzger,  432 


Mettetal,  33,  323 
Meyer,  A,  407,  587 
Meyer,  N.,  163 
Milchner,  80 
Miller,  J.  A.,  225 
Miller,  J.  L.,  555 

Minor,  211,  220,  221,  278,  410,  510 
Mitchell,  Philip,  115 
Moeller,  25,  82,  150,  200 
Mongour,  110,  418 
Monkenberg,  58 
Montgomery,  239 

Montgomery,  CM.,  92,  93,  94,  229 
Monti,  374 
Morgan,  575,  587 
Moritz,  97 
Morland,  174,  543 
Moro,  60,  321 
Morton,  Richard,  152,  208 
Mowat,  Harold,  294 
Much,  Hans,  18,  26,  36,  117,  119,  162 
Muir,  27 

Miiller,  Berthold,  193 
Miiller,  Friedrich,  328 
Miiller,  Hans,  558 
Mlinstermann,  413 
Muralt,  232,  241,  298,  573 
Murphy,  John  B.,  568,  593 
Mlisemeier,  36 

j  Musser,  250,  251,  254,  256,  340 
de  Mussey,  589 

Naegeli,  54,  58 

Neisser,  39 

Newman,  196 

Newsholme,  509 

Nichols,  98 

Niles,  245 

Norris,  George  ,  W.,  92,  262,  282 

Nothnagel,  187 

Nowack,  81 

Oestreich,  263 
Oliver,  98 

Orth,  36,  49,  117,  141 
Osier,  89,  329,  506 
Otis,  Edward  O.,  143 
Overland,  61 

Packard,  40 

Paillard,  152,  154 

Papavoine,  226 

Papillon,  231 

Pappenheim,  226 

Park,  William  H.,  18,  20,  22,  23,  24,  28 

35 
Parr,  139 
Parrot,  127 

Paterson,  210,  472,  475,  516 
Pearce,  49 

Pearson,  Karl,  72,  79,  111,  509 
Pchu,  81 

Penzoldt,  173,  462,  549 
Peretz,  287 
Peter,  Michel,  152,  154 


INDEX  OF  AUTHORS 


625 


Peters,  W.  H.,  140,  412 

Petri,  26 

Petruschky,  323 

Phelps,  483 

PhiUp,  Wilson,  203 

PhiUppi,  543 

Pidoux,  150,  434 

Piery,  82,  112,  142,  279,  365,  574 

von  Pirquet,  33,  60,  95,  318 

Plesch,  259 

Politzer,  226 

PoUak,  59,  203,  434 

Pomeroy,  234 

Pope,  111,  344,  508 

Porter,  80 

Porter,  William,  556 

Potain,  228 

Pottenger,  87,  209,   212,   234,   245,   246, 

248,  272 
Poujade,  474 

Powell,  91,  136,  222,  305,  403,  531 
Preisich,  323 
Price,  196 
Prudden,  133,  135 

QUERNER,  226 

Rabinowitsch,  Lydia,  26,  36,  324,  541 
Rabinowitsch,  Marcus,  36,  117 
Radcliffe,  324 
Radziejewski,  320 
Ramazzini,  96 
Ranke,  69,  381 
Ravenel,  47,  49,  226 
Raw,  94,  435 
Raynaud,  434 
Reed,  Margaret  A.,  225 
Reibmeyr,  239 
Reiche,  187 
Reichenbach,  527 
R^non,  442,  526 
Reuschel,  320 
Revault,  418 

Ribbert,  45,  104,  123,  124 
Riddell,  407 
Riesman,  David,  328 
Ringer,  A.  J.,  225,  560 
Risel,  54 
Rist,  544,  599 
Ritchie,  27 
Ritter,  John,  222 

Riviere,  50,  112,  253,  275,  313,  543 
Rivolta,  22 

Robin,  83,  228,  324,  510 
Robinson,  Beverley,  529,  604 
Robinson,  Samuel,  570,  571,  577,  592 
Rokitansky,  90,  92 
Roily,  320 

Romer,  37,  80,  106,  107,  111,  117,  163 
Rondot,  533 

Ropke,  282,  365,  435,  543 
Roque,  232 
Rosenau,  49 

Rosenberg,  Carolyn,  498 
Rosenberger,  226 
40 


Rossignol,  106 
Rousseau,  200 
Rubel,  471 
von  Ruck,  Karl,  240 
Ruedinger,  344 
Ruge,  418 
Rumpler,  226,  547 
Runge,  81 
RusseU,  83 

St.  Engel,  47 

Sabourin,  174,  182 

Sabrazes,  418 

Sachs,  Theodore,  377 

SahU,  278,  324,  540,  543 

Sander,  35 

Sauerbruch,  600 

Saugman,  110,  176,  570,  573,  678 

Sawyer,  385 

Saxe,  236 

Scheel,  226 

Schern,  226 

Schick,  373 

Schindelka,  93 

Schlossmann,  47,  378 

Schltiter,  79 

Schmorl,  45,  81,  85,  87 

Schroder,  A.,  439,  545 

Schroeder,  E.  C,  20,  40,  48,  49 

Schulze,  87 

Schwatt,  570 

Senator,  229 

Serbonnes,  332 

Sergent,  277,  313,  356 

Sewall,  Henry,  253,  288,  296,  387,  485 

Shingu,  570 

Shortle,  561,  570 

Simon,  164 

Sloan,  570 

Sluka,  389 

Smith,  226,  373,  387 

Smith,  F.  C,  501 

Smith,  Theobald,  19,  21,  29,  35,  37,  50 

Sokolowski,  364,  356,  434 

Sommerfeld,  98 

Sorel,  533 

Sorgo,  36,  186,  200,  320,  547 

Spaltenholtz,  254,  255 

Spieler,  41 

Spindler-Engelsen,  161 

Squires,  J.  Edward,  395,  430,  559 

Stadler,  508 

Staehelin,  404 

Staines,  Minnie  E.,  498 

Steffenhagen,  37 

Stengler,  569 

Stern,  F.,  410 

Stern,  Richard,  100 

Stiller,  87 

Stimson,  A.  M.,  324 

Stokes,  WUliam,  568 

StoU,  382,  384,  387,  389 

Stone,  180 

Strandgaard,  192,  211 

Strauss,  21,  44 


626 


INDEX  OF  AUTHORS 


Strieker,  198,  373,  547 
Strickler,  226 
Stuertz,  600 
Sukiennikow,  382 
Suzuki,  226 
Sweet,  63 
Sydenham,  239 

Tai^ki,  226 

Taute,  25 

Tendeloo,  122,  137,  141,  388 

Tenzer,  320 

Thorn,  111 

Thompson,  R.,  192 

Thompson,  WiUiam  G.,  96,  98 

Thomson,  E.  Hyslop,  476 

Thomson,  St.  Clair,  617 

Thormayer,  415 

Thue,  200 

Tibbies,  521 

Tissier,  519 

Tobiesen,  576 

Tonnelle,  412 

Townsend,  239 

Toyofuko,  107 

Traube,  92 

Tripier,  417 

Trousseau,  90,  215,  418,  558 

Trudeau,  423,  480,  505 

Tuffier,  600 

Turban,  82,  112,  241,  501 

Turk,  519 

Twitchell,  589,  593 

Uhlenhxjt,  160 
UUom,  224 
Ukici,  509 
Ungermann,  48 

Vaillard,  89 
Vanderwelde,  174 
Vaquez,  418 
Vastenburgh,  48 
Vaughan,  34 
Villemin,  17,  21 
Virchow,  371,  547 
Vogeler,  468,  470 
Volk,  106 
Von  den  Velden,  558,  560 

Wagner,  40 
Wainwright,  98 


Walker,  27 

Wallace,  George  B.,  560 

Walsh,  229,  338,  413 

Walsham,  90,  92 

Walshe,  186,  402,  569 

Warren,  B.  S.,  70,  100 

Warren,  E.,  239 

Washburn,  20 

Wassermann,  324 

Watson,  432 

Webb,  106,  205,  344,  471,  498,  587 

Weber,  C,  25,  37 

Weber,  F.  Parkes,  434 

Weber,  Hermann,  111,  438 

Weicher,  112 

Weichselbaum,  44 

Weigert,  122 

Weil,  402 

Weinberg,  79 

Weisz,  432 

Welch,  A.  C,  174 

WeUs,  535 

Wenckenbach,  407 

West,  S.,  90,  94,  194,  253,  400 

Westermeyer,  80 

Weygandt,  241 

Wheaton,  212 

White,  William  Charles,  328,  329,  539 

Whitla,  47,  73 

Widal,  418 

Wiedersheim,  85 

Wiese  174 

WUcox,  Walter  F.,  72 

WiUiams,  C.  Th.,  109,  356,  535 

WUliams,  F.  H.,  294 

Williams,  Mary  E.,  377 

Williamson,  66 

Wilson,  196 

Winsch,  200 

Winslow,  482 

Wintrich,  339 

Wolff,  192,  200 

Wolff-Eisner,  31,  101,  155 

WoUstein,  Martha,  48,  49,  54 

Wolman,  292,  296,  298,  323 

Wood,  47,  258 

Woodruff,  Charles  E.,  95,  242 

Wright,  534 

Wynne,  377 

Zeuner,  97 
Ziehl-Neelsen,  159 


INDEX  OF  SUBJECTS. 


A 


Abortion  in  phthisical  women,  459 
Abortive  ttiberculosis,  365 
diagnosis  of,  368 
physical  signs  of,  367 
symptoms  of,  366 
treatment  of,  601 
climatic,  601 
Abscess  on  chest  wall,  422 

ischiorectal,  413 
Acid-fast  streptothrix,  26 
Acnitis,  214 
Acute  phthisis,  348 

prognosis  of,  424 
treatment  of,  606 
pneumonic  phthisis,  349 
Addison's  disease,  213 
Adenoids,  90 

Adenopathy,  cervical,  380 
bovine  bacilli  in,  28 
tracheobronchial,  337,  376 
diagnosis  of,  390 
pathology  of,  139 
physical  signs  of,  381 
prognosis  of,  391 
skiagraphy  of,  387 
symptoms  of,  376 

reflex,  387 
treatment  of,  607 
Adrenalin  in  hemoptysis,  560 
Adrenals,  213 

Age-incidence  of  tuberculosis,  53,  55,  59, 
1       67,  70,  369 
\  Air,  stagnant,  482 
■\"  Alarm  zone,"  313 
Albuminuria,  228,  420 
Alcohol,  611,  212 
Allergy,  95,  106,  320,  371 
Allyl,  522 
Alopecia,  214 
Altitude  and  frequency  of  tuberculosis, 

63 
Amenorrhea,  147,  238 
Amphorophony,  289,  343 
Amyloid,  229 
Anaphylaxis,  32 
Anasarca,  230 
Anatomy,  morbid,  121 
Anemia,  224, 
Anergy,  95,  451 
Anesthesia  in  phthisical  patients,  429 


Anorexia,  203 

in  advanced  phthisis,  207 

causes  of,  205 

diet  and,  516 

treatment  of,  564 
Antagonistic  diseases,  229,  433 
arteriosclerosis,  434 
cardiac,  91 
gout,  434 
nephritis,  434 
scrofula,  112 
syphilis,  435 
Antibodies,  31,  541 
Antiformin,  160 
Antigens,  324 
Antiphymose,  434 
Antipyretics,  415 
Apex,  appearance  in  fluoroscope,  293 

percussion  of,  264 

predisposition  of,  84 
Apical  catarrh,  327 
Appendicitis.  415 
Appetite,  203 

Arneth's  blood  picture,  225 
Arsenic,  532 

symptoms  of  intolerance  of,  533 
Arteriosclerosis,  434 
Ascites,  414 
Asthma,  90,  358 
Athrepsia,  373 
Atoxyl,  533 

Atropin,  in  hemoptysis,  560 
Auscultation,  275 

in  abortive  tuberculosis,  367 

in  advanced  phthisis,  336 

in  aged  patients,  396 

in  bronchial  adenopathy,  385 

in  incipient  phthisis,  313 

in  pneumothorax,  405 

single-phase,  276 

sources  of  error  of,  282 

technic  of,  275 
Auto-inoculation,  476,  477 
Autoserotherapy,  590,  613,  616 
Autosuggestion.     See  Suggestion,  236. 
Avian  bacilli,  21,  24,  28 


Bacilli,  tubercle,  17 
acid-fast,  18 


628 


INDEX  OF  SUBJECTS 


Bacilli,  tubercle,  atypical,  36 
avian,  21 
bovine,  23,  28,  29 
channels  of  entry  of,  37,  44 
cultivation  of,  19 
diagnostic  value  of,  27 
effects  of,  on  tissues,  29 
in  healed  lesions,  33 
human,  23,  27 
inhalation  of,  38 
microscopic    examination    for, 

159 
morphology  of,  17 
mutation  of,  36 
as  parasites,  35 
poisons  from,  29 
powers  of  resistance  of,  19 
pseudotubercle,  25,  26 
reptilian,  25 
spores  in,  18,  19 
in  sputum,  52,  162 
staining  of,  18,  159 
virulence  of,  22 
Bacillus  carriers,  53,  394 
grass,  25 
leprae,  25,  27 
smegma,  25,  27 
Bacteria,  pyogenic,  135 
Bang  system,  82,  113 
Baths,  465 
BeU  sound,  405,  407 
Biermer's  phenomenon,  341,  405 
Birds,  tuberculosis  in,  23,  25 
Blood,  224 

effects  of  high  altitude  on,  498 
erythrocytes  in,  224 
leukocytes,  224 
platelets,  225,  498 
tubercle  bacilli  in,  226 
Blood-pressure,  222 

in  incipient  phthisis,  311 
Blood-serum,  for  hemoptysis,  561 
Bones,  tuberculosis  of,  68 
Bovine  baciUi,  22,  28 

in  children,  36 
immunity  to,  49,  114,  115 
ini  man,  28,  35 
mutation  of,  36 
in  phthisis,  28 
prophylaxis  of,  449 
Bradycardia,  222 

Breath  sounds  in  advanced  phthisis,  236 
amorphic,  341,  405,  407 
bronchial,  281 
broncho  vesicular,  281 
cavernous,  341 
in  children,  386 
cog-wheel,  279,  313 
feeble,  277 
granular,  278 
metamorphosed,  342 
normal,  277 
rough,  278 
Bronchiectasis,  133,  343 
hemoptysis  in,  196 


Bronchitis,  329 

fetid,  157 
Bronchophony,  287 
Bronchopneumonia,  tuberculous,  352 

diagnosis  of,  354 

etiology  of,  352 

in  infants,  372,  373 

prognosis  of,  354 

symptoms  of,  352 

treatment  of,  607 
Bulimia,  205,  207 
Butcher's  wart,  38 
Butter  as  a  food,  521 

tubercle  bacilli  in,  20,  26 


Cacodylates,  532 
Cachexia,  208 

in  children,  273 
Calcification,  125,  137 
Calcium  in  hemoptysis,  561 
Carbohydrates  as  foods,  522 
Cardiac  displacement,  335,  344,  362 

weakness,  treatment  of,  563 
Cardiovascular  system,  219 
"Carriers,"  53,  118,  162,  394 
Caseation,  123 
Catarrh,  apical,  327 
Cattle,  tuberculosis  in,  23 
Cavities,  132 
bacilli  in,  34 
basal,  343 

bleeding  from,  136,  188 
bronchiectatic,  133 

in  aged  patients,  395 
closed,  136 
cough  in,  154 
diagnosis  of,  338 
phantom,  343 

prognostic  significance  of,  430 
skiagraphy  of,  299 
sputum  from,  157 
tympany  over,  339 
whispered  voice  over,  289 
Cerebrospinal  fluid,  416 
Cheese  as  a  food,  520 

tubercle  bacilli  in,  20 
Chest,  normal,  245 

appearance  on  skiagram,  291 
in  incipient  phthisis,  311 
in  infants,  383 
phthisical,  244,  250,  383 
Children,  pulmonary  tuberculosis  in,  53, 
65,  369 
bovine  infection  of,  28 
characteristics  of,  369 
prognosis  of,  389 
skiagraphy  in,  388 
symptoms  of,  375 
treatment  of,  607 
tuberculin  test  in,  59 
Chloasma  phthisicorum,  213,  244 
Chlorosis,  224,  309 


/ 


INDEX  OF  SUBJECTS 


'629 


Circumcision,  infection  of  wound,  38,  113 
City  life  and  tuberculosis,  64,  74 
Civilization  and  tuberculosis,  53,  61 
Classification  of  phthisis,  305 

official,  302 
Climate  and  infection,  61,  63 
Climates,  desert,  503 
mountain,  497 

contra-indications,  500 
indications  for,  499 
influence  on  heart,  501 
on  hemoptysis,  501 
sea,  501 
Climatic  treatment,  492 
cost  of,  493 

economic  aspects  of,  492 
Clothing,  466 
Clubbed  fingers,  214 

in  fibroid  phthisis,  358 
Cod-liver  oil,  434 

administration  of,  536 
contra-indications  of,  536 
indications  of,  536 
Cog-wheel  breathing,  279 
Cold,  effects  on  tubercle  bacilli,  20  _ 
Cold-blooded  animals,  tuberculosis  in,  25 
Colds  as  predisposing  factors,  89 

tubercle  bacilli  in,  317 
Collapse  during  hemorrhages,  191 

in  spontaneous  pneumothorax, 

402 
treatment  of,  563 
Collapse-induration,  274,  326 
Complement-fixation  test,  324 

iti  abortive  tuberculosis,  367 
Complexion,  62,  212,  224,  242 
Comphcations,  398 

abscess  on  chest  waU,  422 
cardiac,  417 
empyema,  400 
gangrene  of  lung,  401 
intestinal  ulcerations,  412 
laryngeal  tuberculosis,  408 
meningitis,  416 
myocarditis,  417 
pericarditis,  417 
peritonitis,  413 
phlebitis,  418 
pleurisy,  dry,  395 

moist,  398 
pneumothorax,  401 
purpura,  421 
thrombosis,  418 

influence  on  prognosis,  428 
in  urogenital  tract,  420 
Conjugal  phthisis,  110 
Constipation,  207 

in  meningitis,  416 
in  peritonitis,  415 
treatment  of,  566 
Corset,  466 
Cough, 150 

in  abortive  tuberculosis,  366 

in  acute  phthisis,  350 

in  advanced  phthisis,  154,  332 


Cough  in  bronchial  adenopathy/378 

diagnostic  significance  of,  ^55 

emetic,  152 

treatment  of,  551 

in  fibroid  phthisis,  35,5 

frequency  of,  150     / 

hJ^sterical,  151,  155 

in  incipient  phthisis,  150,  309 

paroxysmal,  151 
in  infants,  373 

prognostic  significance,  155 

treatment  of,  548 
medicinal,  550 
psychotherapy,  548 
"Cough  phenomenon,"  293 
Cracked-pot  resonance,  339,  341 
Creosote,  527 

administration  of,  528 

carbonate,  530 

cinnamate,  530 

contra-indications  for,  528 

for  cough,  550 

in  gastritis,  565 

indications,  528 

inhalation  of,  529 
Crepitation,  283 
Cure,  tendencies  to,  440 
Cuspidors,  456 
Cyanosis,  212 


D 


Death,  modes  of,  346 

from  pulmonary  hemorrhage,  200 

in  laryngeal  tuberculosis,  412 

premonitory  signs  of,  346 

rates  from  tuberculosis,  70 

temperature  before,  180 
Degeneration,  amyloid,  142 

fibroid,  125 
Delirium,  235,238 
Deminerahzation,  83 
Dermographism,  232 
Desert  climate,  503 
D'Espine's  sign,  386 
Dextrocardia,  262,  336 
Diabetes,  93,  147 

and  artificial  pneumothorax,  594 
Diagnosis  by  animal  inoculation,  163 

differential,  326 

apical    induration    in    cardiac 

disease,  327 
bronchiectasis,  329 
chronic  bronchitis,  329 
collapse  induration,  326 
from  pneumonic  processes,  327 

hasty,  143 

natural  method  of,  146 

principles  of,  145 
Diaphragm  in  skiagram,  294 
Diarrhea,  208 

due  to  intestinal  ulceration,  412 

treatment  of,  566 

in  uremia,  230 
Diathesis,  arthritic,  434 


630 


INDEX  OF  SUBJECTS 


Diazo  reaction,  432 

Diet,  individualization  of,  510 

in  hemoptysis,  561 
Dietaries,  523 
Dietetic  treatment,  513 

in  anorexia,  516,  564 
in  constipation,  566 
in  diarrhea,  566 
economic  aspects  of,  513 
individuahzation  in,  510,  513 

>i^    needs  for  special,  515 
weight  and,  514 
Digitalis  in  hemoptysis,  560 
Diphtheria  of  Imigs,  328 
Disease  vs.  infection,  52,  67 
Diseases,  antagonistic,  90,  112 
Dispensaries,  509 
Displacements  of  heart,  335,  344,  362 

of  trachea,  344 

of  viscera,  357 
Droplet  infection,  41,  455 
Duotal,  530 
Dust,  96 

effects  of,  on  lungs,  97 

in  etiology  of  fibroid  phthisis,  536 

infectivity  of,  39,  40 

tubercle  bacilli  in,  20 
Dyspepsia,  203 
Dysphagia,  409,  412 

in  artificial  pneumothorax,  588 

treatment  of,  617 
Dysphionia,  409 
Dyspnea,  220 

effects  of  work  on,  473 

in  fibroid  phthisis,  359,  363 

in  spontaneous  pneumothorax,  402 

treatment  of,  562 

in  tuberculosis  in  the  aged,  395 


E 


Economic  conditions,  463 

influence  of,  on  prognosis,  433 
Edema,  210 

cachectic,  420 

of  legs,  419 

terminal,  429 
Eggs  as  a  food,  520 
Egotism,  236 
Elastic  tissue,  163 

in  diagnosis  of  cavities,  338 
Emaciation,  176 

in  acute  phthisis,  350 

in  advanced  phthisis,  334 

in  arrested  disease,  436 

in  artificial  pneumothorax,  584 

in  children,  376 

effects  of,  209 

in  fibroid  phthisis,  358 

in  incipient  phthisis,  310 

in  infants,  373 

in  peritonitis,  416 

in  phthisis  in  the  aged,  395 

prognosis  of,  210 


Embolism,  419 

gas,  586 
Embryo,  tubercle  bacilli  in,  80,  81 
Emetin  in  hemoptysis,  558 
Emphysema,  90 

appearance  of,  on  radiogram,  299 

cutaneous,  587 

mediastinal,  588 

pathology  of,  132 
Empyema,  400 

prognostic  significance  of,  429 

treatment  of,  614 
Endocarditis,  92 

verrucosa,  417 
Epidemiology,  52 
Epididymitis,  421 
Ergot  in  hemoptysis,  560 
Eugenics  and  tuberculosis,  459 
Euphoria,  326,  334,  346,  416 
Euthanasia,  236 
Exercise,  475 

effects  of,  on  temperature,  169,  172, 
182 

sweating  during,  185 
Exotoxin,  539 
Expectoration,  156 

treatment  of,  552.      See  also  Spu- 
tum 
Experimental  vs.  cUnical  data,  50 
Exposure  and  infection,  62 

history  of,  in  diagnosis,  147 

of  infants,  448 
Extrapleural  pneumolysis,  600 


Facies,  242 

in  tuberculous  infants,  373 
Fat  as  a  food,  521 

in  eggs,  520 

intolerance  to,  205 

phthisis,  181,  211,  358,  434 
treatment  of,  607 
Fetus,  tuberculosis  of,  79,  81,  371 
Fever,  166 

in  abortive  tuberculosis,  366 

in  advanced  tuberculosis,  333 

antipj'retics  in,  555 

continuous,  177,  554 

cyclic,  177 

diagnostic  significance  of,  182 

due  to  complications,  181 

effects  of  artificial  pneumothorax  on, 
583 
of  rest  on,  473,  474 

in  fibroid  phthisis,  358,  363 

hectic,  177,  554 
cause  of,  34 

hydrotherapy  of,  554 

hysterical,  175 

in  incipient  phthisis,  170,  310 

influence  of  hemoptj'sis  on,  201 

medication  for,  604 

menstrual,  173,  553 


INDEX  OF  SUBJECTS 


631 


Fever,  mixed  infection  in,  34 
mountain  climate  for,  500 
in  phthisis  in  aged,  395 
in  pleural  effusion,  589 
prognostic  significance,  182,  427 
provoked,  172 
pulse  in,  172 

reversed  type,  174,  176,  427 
symptoms  of,  172 

in  tracheobronchial  adenopathy,  377 
treatment  of,  552 
in  tuberculin  reactions,  322 
in  tuberculous  bronchopneumonia, 
350 
Fibroid  phthisis,  335 
in  aged,  395 
cough  in,  151 
course  of,  359 
diagnosis  of,  360 
emphysematous  form,  358 
etiology  of,  356 
forms  of,  357 
hemoptysis  in,  189,  191 
pleural  form,  361 
prognosis  of,  363 
treatment  of,  606 
Fish  as  a  food,  521 
Fluoroscopy,  293 

in  children,  388 
Focal  reaction,  322 

from  creosote,  527 
from  iodides,  533 
Foods,  carbohydrates,  522 
cheese,  520 
condiments,  522 
eggs,  520 
fish,  521 
milk,  519 

nutritive  value  of,  514 
proteins,  518 
salts,  522 
variety  of,  516 
Football  as  a  cause  of  phthisis,  101 
Forced  feeding,  514 

Fowls,  susceptibility  to  tuberculosis,  25 
Fremitus,  vocal,  252 
Friction  sounds,  286,  399 
Friedreich's  phenomenon,  340 


G 


Gabbett's  stain,  159 
Galloping  consumption,  348,  352 
Games,  478 

indoor,  479 

outdoor,  478 
Gangrene  of  lung,  157,  401 
Gastric  disturbances,  153,  203 

treatment  of,  565 
Gelatin  in  hemoptysis,  560 
Genius,  237 

Gerhard t's  phenomenon,  340 
Germinative  transmission,  79 
Giant  cells,  30,  122 


Giarit  cells  in  fibrosis,  355 
Gout,  434 

and  fibroid  phthisis,  356,  360 
Glands,  bronchial,  376 

anatomical  relations  of,  47 

cervical,  28,  47,  380 
■    enlarged,  244 

hilus,  skiagraphy  of,  292 

mesenteric,  29 

supraclavicular,  381 
Glycerophosphates,  531 
Glycosuria,  93 
Graduated  labor,  210,  476 
Granules,  Much's,  18 

staining  of,  162 
"Grape  cure,"  442 
Grass  bacillus,  25 
Grocco's  triangle,  400,  589 
Guaiacol,  530 

antipyretic  action  of,  555 

carbonate,  530 


H 


Habitus  phthisicus,  242,  383 
Hair,  214 

Handkerchiefs,  457 
Hasty  consumption,  348 
Headache,  416 
Head's  zones,  233 
Healed  lesions,  55 
Heart  disease,  91,  328 

displacement  of,  335 

hemoptysis  and,  195 

pathology  of,  142 

size  of  phthisis,  91 
Heat,  effect  of,  on  tubercle  bacilli,  19 
Hectic  fever,  179,  183 
Hematemesis,  207 

and  hemoptysis,  198 
Hematogenic  infection,  45 

in  children,  369 
Hemoptysis,  186 

in  abortive  tuberculosis,  366,  368 

in  acute  phthisis,  353 

in  advance  phthisis,  335,  190 

in  arrested  disease,  436 

arthritic,  195 

artificial  pneumothorax  for,  584,  591 

in  bronchiectasis,  329 

blood-pressure  in,  223 

causes  of,  192,  199 

deaths  due  to,  200,  346 

diagnostic  significance  of,  194 

during  menopause,  612 

epidemics  of,  193 

false,  195 

fatal,  191,  193 

in  fibroid  phthisis,  189,  191,  359,  363 

high  altitude  and,  501 

in  incipient  tuberculosis,  311 

influence  on  course  of  disease,  201 

initial,  186,  199 

menstrual,  196 


632 


INDEX  OF  SUBJECTS 


Hemoptysis  at  onset  of  phthisis,  189 

pathology  of,  136,  187 

in  phthisis  in  the  aged,  396 

premonitory  symptoms  of,  190 

prognostic  significance  of,  199,  426, 
428 

seasonal  uifluences,  193 

sexual  differences,  192 

spurious,  195 

terminal,  188 

traumatic,  101 

treatment  of,  556 
diet  in,  561 
medicinal,  559 
prophylactic,  556 

tuberculin  treatment  of,  effects  on, 
547 
Hemorrhages,  intestinal,  412 
Hemorrhagic  phthisis,  359 
Heredity,  77 

clinical  facts  of,  81 
Hermann  stain,  160 
Hernia,  157 
Herpes  zoster,  213 

Heterosuggestion,  235.      See  Suggestion 
Hilus  shadow,  292 

in  children,  389 
"dimple,"  383 
Historj^  of  patient,  146 

of  present  iHness,  148 

prognostic  significance  of,  425 

unrehability  of,  78 
Hoarseness,  156 

in.  incipient  tuberculosis,  311 

in  laryngeal  tuberculosis,  409 
Home  treatment,  481 
Housing  conditions,  74,  458 
Hydropneumothorax,     341,     402,    589, 

616 
Hydrotherapy  for  fever,  554 
HjT^eracidity,  treatment  of,  565 
Hyperesthesia,  233 

Hypersensitiveness  to  foreign  proteins, 
323 

phenomena  of,  31 

to  tuberculin,  317,  540 
HyperthjToidism,  311 
Hypophosphates,  534 
Hypotension,  arterial,  222 


ICHTHYOL,  531 

Idiocj'^,  235 

Immigrants,  tuberculosis  among,  62 

Immunity,  106,  114 

chnical  proof  of,  112 

experimental  proof  of,  106 

failure  of,  115 

through  tuberculin,  32,  430,  540 
Immunization  with  acid-fast  bacilli,  25 
Incipient  phtliisis.     See  Phthisis 
course  of,  331 
treatment,  601 


Indians,  American,  tuberculosis  among, 

61,  62 
Infancy,  tuberculosis  in,  371 
diagnosis  of,  374 
morbidity'  during,  447 
prognosis  of,  374 
prophjdaxis  of,  446 
symptoms  of,  372 
Infants,  newborn,  freedom  for  tuberculo- 
sis, 54,  79,  81,  371 
Infection,  35 

of  adults,  41,  56,  451 
of  aged  persons,  394 
barriers  against,  43 
benevolent,  452 
bovine,  49,  115,  449 
in  adiilts,  28 
in  children,  27 
bronchogenic,  45 
of  children,  58,  449 
contact,  38,  42 
disease  and,  52,  67,  375 
droplet,  455 

exposui-e  and,  62,  65,  147,  315 
familial,  371 
of  fetus,  81 
frequency  of,  53 
hematogenic,  38,  45 
housing  conditions  and,  40 
of  infants,  448 
by  ingestion,  46 
by  inhalation,  39,  42 
lymphogenic,  46 
mixed,  34,  135 
primary,  371 
problems  of,  35 
in  rural  populations,  61 
secondary,  34 

social  and  economic  factors,  65 
spermatogenic,  80 
through  sweat,  185 
imder  normal  conditions,  40 
wages  and,  66 
Influenza,  95 

epidemic  of,  553 
uifluence  on  prognosis,  429 
tubercle  bacilU  in,  317 
Inhalation  of  bacilli,  39 

in  children,  369 
Injury  as  cause  of  phthisis,  100 
Insanity,  235 
Insomnia,  151,  237 

treatment  of,  563 
Inspection,  242 

in  incipient  phthisis,  311 
technic  of,  246 
Intellect  of  consumptives,  237,  334 
Internal  secretions,  82,  535 
Intestine,  tuberculosis  of,  210 
diagnosis  of,  413 
perforation  of,  414 
symptoms  of,  207 
ulcerations  of,  208,  412 
Intestines,  infection  of,  49 

pathological  changes  in,  141 


INDEX  OF  SUBJECTS 


633 


Iodides,  533 

in  fibroid  phthisis,  607 
promoting  expectoration,  159 

Ischiorectal  abscess,  428     . 

Isolation  of  tuberculous,  448 


Joints,  bovine  bacilli  in,  28 
tuberculosis  of,  68 


Kidneys,  227 

amyloid  of,  229,  421 

tuberculosis  of,  diagnosis  of,  421 
ICronig's  resonant  areas,  264 

in  incipient  phthisis,  312 
Kyphoscoliosis,  218 
Kyphosis,  248 


Labor,  effect  of  disease  on,  239 
Lagging,  246    ^ 

significance  of,  247 
Languor,  174,  310 

Larynx  in  artificial  pneumothorax,  594 
tuberculosis  of,  146,  156,  346,  408 
diagnosis  of,  409 
frequency  of,  408 
prognosis  of,  411 
symptoms  of,  408 
treatment  of,  616 
"Larynx  sign,"  410 
Latent  lesions,  55 
Lepra  bacilli,  25,  27 
Leprosy,  33 

tuberculin  reaction  in,  33 
Lesions,  tuberculous,  among  healthy,  58 
frequency  in  children,  53 

at  autopsies,  54 
initial,  45 
repair  of,  137 
Leukocytosis,  224,  225 
Life  insurance  and  tuberculosis,  66 
Light,  effect  of,  on  bacilli,  20 
Lime  starvation,  83 
Lips,  tuberculous  ulcers  of,  421 
Lumbar  puncture,  416 
Lung  blocks,  67 
Lungs,  cavities  in,  132 
diphtheria  of,  328 
extension  of  lesion  in,  129 
insusceptibility  of,  234 
resistance  of,  against  infection,  43 
tubercles  of,  126 
Lupus,  vulgaris,  38 
Lycopodium  simulating  tubercle  bacilli, 

317 
Lymph  glands,  cervical,  28 
mesenteric,  29 
reaction  to  infection,  369 
Lysin,  31 


M 


Malaria  complicating  phthisis,  181 
Malt,  537 
Manometer,  573 

functions  of,  573 
Manometric  hints,  578 
Marriage  of  tuberculous,  458 
Meat,  518 

eating  and  phthisis,  434 
raw,  518 

tubercle  bacUli  in,  20,  22 
Medication  and  hemoptysis,  193 
Medicinal  treatment,  525 

in  advanced  phthisis,  603 
in  diarrhea,  566 
harmless,  526 
Meningitis,  bovine  bacilli  in,  28  _ 
in  infants,  372,  373 
tuberculous,  symptoms  of,  416 
Menopause,  tuberculo'sis  during,  612 
Menstruation,  147 

disturbances  of,  238 
fever  during,  173 
hemoptysis  during,  196 
vicarious,  197 
Mercury  succinimide,  534 
Metabolism,  82 
purin,  435 
Metalic  tinkle,  342,  405 
Milk  in  diet,  519 
fermented,  520 
infectiousness  of,  21 
tubercle  baciUi  in,  19,  21,   26,   36, 
49 
"Milk  cure,"  442,  519 
Miners,  tuberculosis  among,  79,  98 
Mitral  stenosis,  91,  329 

hemoptysis  in,  196 
Mixed  infection,  34,  135,  401 
Morbidity,  influence  of  age  on,  68 

rates,  70 
Moro  test,  321 
Morphin  in  hemoptysis,  557 
MortaUty,  tuberculous,  63,  70 

according  to  age  periods,  68 

to  sex,  69 
in  cities,  67 
decline  of,  70 

causes  of,  71 
of  infants,  447 
morbidity  and,  64,  67 
urbanization  and,  74 
Mountain  climates,  497 
Much's  granules,  18 

in  fibroid  phthisis,  357 
staining  of,  162 
Murmur,  hemic  in  infraclavicular  space, 

314 
Murmurs,  cardiac,  in  phthisis,  92 
Muscles  during  incipient  stage,  311 
pathological  changes  in,  142 
spasm  of,  246,  248 
wasting  of,  209 
Myocarditis,  417 


634 


INDEX  OF  SUBJECTS 


N 


Nails,  214 

Negroes,  tuberculosis  in,  62,  74 
Nephritis,  228,  420,  434 
Nervous  symptoms,  231 
Neurasthenia,  231,  309 
Nightsweats,  183 

in  bronchial  adenopathy,  378 

causes  of,  183 

in  children,  378 

in  incipient  phthisis,  311 

in  phthisis  in  the  aged,  396 

treatment  of,  556 
Nitrites  in  hemoptysis,  559 
Nose,  tubercle  bacilli  in,  41 


Obesity,  211,  434,  475,  514 

treatment  of,  607 
Ochrodermia,  224 

Occupation  as  a  cause  of  fibroid  phthisis, 
356 
for  arrested  cases,  605,  467 
tuberculosis  and,  67,  69,  96 
for  tuberculous  patients,  467 
Oliguria,  228 
Onset,  148 

of  acute  phthisis,  350 
prognosis  at,  426 

with  hemoptysis,  187,  189,  193,  199 
Open-air  schools,  609 
treatment,  480 

of  children,  608 
contra-indications,  491 
for  febrile  patients,  488 
results  attained  by,  490 
technic  of,  483 
vs.  climatic  treatment,  481 
Ophthalmoreaction,  321 
Opiates  in  cough,  550 
Opsonins,  225,  236,  477 
Orphan  asylums,  rarity  of  tuberculosis 

in,  391 
Orthoform,  618 

Osteo-arthropathy,  pulmonary,  217 
Overcrowding  and  tuberculosis,  66 
Overfeeding,  fever  from,  553 

symptoms  of,  523 
Ovum,  infection  of,  79 
Ozone,  497 


Pains  in  artificial  pneumothorax,   583, 
587 

in  chisst,  232 

treatment  of,  564 
Palpitation,  cardiac,  219,  242 

in  fibroid  phthisis,  363,  366 
Parrot's  law,  127 
Pasteurization  of  milk,  20 
Pathologist's  wart,  38 


Pathology,  121' 

of  incipient  lesions,  45 
of  senile  phthisis,  394 
Pectoriloquy,  288,  342 
Percussion,  253 

in  abortive  tuberculosis,  367 
in  advanced  phthisis,  273,  335 
aims  of,  253 

in  bronchial  adenopathy,  384 
comparative,  261 
diagnostic  value  of,  274 
hooked-finger,  259 
in  incipient  phthisis,  312 
over  excavations,  338 
respiratory,  264,  313 
sources  of  error,  269,  273 
in  spontaneous  pneumothorax,  405 
technic  of,  255 
tidal,  272 

in  various  stages  of  phthisis,  435 
Percutaneous  tuberculin  test,  321 
Pericarditis,  417 
Perichondritis,  409,  411 
Peritonitis,  tuberculous,  413 

symptoms  of,  414 
Personal  hygiene,  464 
Phagocytosis,  122,  123 
Phlebitis,  230,  418 
Phrenikotomie,  600 
Phthisiogenesis,  103 
Phthisiophobia,  151,  433,  453,  499 
Phthisiotherapy,   psychic  influences  in, 

447 
Phthisis,  acquired  during  childhood,  104 
acute,  348 

cause  of,  351 
diagnosis  of,  351 
sjTnptoms  of,  349 
treatment  of,  606 
advanced,  331 

duration  of,  344,  441 
physical  signs  of,  335 
symptoms  of,  332 
treatment  of,  602 
medicinal,  603 
in  aged,  394 

course  of,  396 
etiology  of,  394 
frequency  of,  394 
physical  signs  of,  396 
symptoms  of,  395 
treatment  of,  611 
bovine  bacilli  in,  28 
clinical  forms  of,  301 
complications  of,  302 
confirmata,  302 
conjugal,  110 
curability  of,  423,  435 
desperata,  302 
diabetes  in,  93 
factors  predisp>osing  to,  76 
familial,  78 

fibroid.     See  Fibroid  phthisis 
hemoptysis  in,  influence  of,  201 
hemorrhagic,  192 


INDEX  OF  SUBJECTS 


635 


Phthisis,  incipient,  302 

duration  of,  303,  330 
elements  of  diagnosis  of,  315 
onset  of,  308 
physical  signs  of,  311 
symptoms  of,  309 
treatment  of,  601 
climatic,  499 
a  manifestation  of  immunity,   106, 

114 
marital,  110 
mitral  disease  and,  92 
occulta,  302 
pathology  of,  121 
polymorphism  of,  76,  301 
prevention  of,  452 
progn,osis  of,  423 
rarity  of,  in  children,  369,  450 
stages  of,  302 
syphiUs  and,  105 
traumatic,  100 
wages  and,  66,  100 
von  Pirquet  reaction  among  well-to-do, 
65 
frequency  of,  in  children,  59 
Pityriasis  tabescentium,  213,  244 

versicolor,  213 
Placental  transmission,  80,  81 
Pleura,  adhesions  of,  137,  596 
pathological  changes  in,  141 
rupture  of,  137 
in  skiagraphy,  299 
Pleural  shock,  585 
Pleurisy,  88,  147 

in  artificial  pneumothorax,  588 
dry,  398 

influence  of,  on  prognosis,  426,  428 
locahzed,  399 
moist,  398 
pains  in,  234 
traumatic,  101 
treatment  of,  613 
tuberculous,  181 
Pleuropericardial  frictions,  286 
Pleximeter,  257 

hooked-finger,  259 
Plumbism,  435 
Pneumokoniosis,  79,  97 
Pneumonia,  caseous,  128 

lobar,  in  phthisis,  429 
Pneumopericardium,  407 
Pneumothorax,  amphoric  phenomena  in, 
341 
artificial,  568 

in  advanced  phthisis,  592 
apparatus  for  induction,  573 
bilateral,  592,  597 
Brauer's  method,  570 
complications  of,  585 
emphysema,  587 
pains,  587 

pleural  effusion,  588 
spontaneous     pneumotho- 
rax, 587 
contra-indications  to,  594 


Pneumothorax,    artificial,    duration    of 
treatment,  597 
dyspnea  in,  584 
fibrous  phthisis  after,  362 
final  pressure  allowed,  582 
Forlanini's  method,  521 
frequency  of  refills,  582 
gas  embolism  in,  586 
used  for,  575 
,  for  hemoptysis,  559,  592 

history  of,  568 
indications  for,  590 
injection  of  gas,  580 
in  intestinal  tuberculosis,  594 
in  laryngeal  tuberculosis,  594 
local  anesthesia  in,  577 
method  of  induction  of,  570 

in  urgent  cases,  580 
Murphy's  method,  571 
needle,  578 
partial,  597 
physical  signs,  585 
pleural  adhesions,  596 

shock,  585 
principles  underlying,  570 
proportion  of  cases  suitable  for, 

596 
pupils  in,  332 
results  of  treatment,  598 
selection  of  point  for  injection, 

576 
symptoms  of,  582 
technic  of  induction,  570,  578 

of  refilling,  581 
thoracocentesis,  577 
diagnostic,  593 
hemoptysis  and,  197 
pathology  of,  137 
pectoriloquy  in,  383 
"providential,"  616 
spontaneous,  401 

in  artificial  pneumothorax,  587 
closed,  403 
diagnosis  of,  406 
double,  404 
in  fibroid  phthisis,  364 
frequency  of,  402 
latent,  404 
mortality  from,  401 
open,  403 
partial,  404 
physical  signs  of,  404 
symptoms  of,  402 
treatment  of,  614 
treatment  of,  616 
whispered  voice  in,  289 
x-rays  in  diagnosis  of,  299 
Poisons  of  tubercle  bacilli,  29 
Polyuria,  227 
Porches,  sleeping,  486 
Poverty  in  prognosis  of  phthisis,  433 

tuberculosis  and,  58,  59,  60,  66 
Predisposition,  113 

anatomical  factors,  S3 

diseases  of  heart  and  bloodvessels,  91 


636 


INDEX  OF  SUBJECTS 


Predisposition    diseases    of    respiratory 
tract,  88 

influenza,  95 

injury,  100 

measles,  94 

natvire  of,  116 

theories  of,  77 

typhoid  fever,  95 

whooping-cough,  94 
Pregnancy,  artificial  pneumothorax  and, 
594 

effect  on  phthisis,  238,  429,  459 
Prevention  of  disease,  466 

of  infection,  446 
Printers,  tuberculosis  among,  96 
Procreation  by  phthisical  patients,  459 
Prognosis,  423 

in  abortive  tuberculosis,  425 

activity  of  disease  and,  427 

in  acute  phthisis,  424 

Arneth's  blood  picture  in,  225 

in  arrested  disease,  435 

complement-fixation  and,  432 

comphcations  and,  428 

elements  of,  424 

emaciation  and,  436 

fever  and,  182,  427 

in  fibroid  phthisis,  425 

hemoptysis  and,  426,  428,  436 

importance  of,  423 

in  infants,  374 

influence  of  economic  conditions  on, 
433 

initial  hemoptysis,  412 

of  laryngeal  tuberculosis,  411 

physical  signs  in,  429 

pleurisy  in,  428 

of  pnemnothorax,  407 

pulse  in,  428 

special  tests  in,  431 

thrombosis  and,  421 

in  tuberculosis  in  children,  374,  391 

of  various  forms  of  phthisis,  429 
ProUflcity  of  tuberculous,  239 
Prophylaxis,  446 

in  adults,  451,  454 

in  children,  449 

duties  of  community  in,  457 

failure  of,  75 

in  infants,  448 

of  phthisis,  452 

of  reinfection,  450 
Pseudotubercle  bacUH,  25,  26,  226,  316 
Psychasthenia,  231 
Psychic  influences,  442 

traits,  335 
Psychology  of  tuberculous,  235 
Psychotherapy,  44,  545 
Pulse,  220 

in  abortive  tuberculosis,  367 

in  aged  patients,  395 

fever  and,  171 

hemoptysis  and,  202 

in  incipient  tuberculosis,  311 

influence  of  rest  on,  473 


Pulse,  instability  of,  220,  221 
prognostic  value  of,  428 
slow,  227 
Pupfls,  232,  237,  243 
Purpura,  421 
Pyelitis,  tuberculous,  421 
Pyopneumothorax,  402 
Pyrexia.     See  Fever,  166 


Race  and  susceptibihty  to  tuberculosis, 

62 
Radiography.     See  Skiagraphy,  290 
Rales  in  abortive  tuberculosis,  367 
in  advanced  phthisis,  337 
after  hemoptysis,  337 
atelectatic,  287 
cavernous,  342 
crepitant,  283 
differentiation  from  frictions,  286 

from  muscle  sounds,  287 
in  incipient  phthisis,  314 
marginal,  287 
moist,  284 
sibflant,  285 
sonorous,  285 
spmious,  286 
transmitted,  593 
Reaction,  tuberculin,   clinical  value  of, 
322 
conjvuictival,  321 
cutaneous,  33,  318 

sjonptoms  of,  319 
dangers  of,  324 
diagnostic  value  of,  323 
focal,  540 

to  foreign  proteins,  33 
intensity  of,  546 
in  leprosy,  33 
local,  318 

to  non-tuberculous  proteins,  32 
phenomena  of,  33 
specificity  of,  32,  320,  323 
in  syphilis,  33 
Reflex    symptoms   in    bronchial    aden- 
opathy, 388 
Reflexes,  232 

Reinfection,  autogenic,  117 
endogenic,  117 
exogenic,  119 
in  hospital  inmates,  108 
in  human  beiags,  108 
metastatic,  117 
prophylaxis  of,  450 
Relapses,  344 

dangers  of,  605 
Remineralization,  534 
Renal  system,  227 
Reptflian  tubercle  bacilU,  25 
Resistance  of  tubercle  bacilli,  19 

natural,    against   tuberculosis,    301, 

305 
racial,  62 


INDEX  OF  SUBJECTS 


637 


Rest  cure,  471 

contra-indications,  474 

for  fever,  554 

indications  for,  472 

principles  of,  471 

technic  of,  473 
functional,  of  lung,  569 
Rib,  shortening  of  first,  84 
Ribs,  appearance  of,  in  skiagram,  293 


Sajodin,  533 

Salt,  in  hemoptysis,  558 

Sanatorium  treatment,  505 

for  incipient  phthisis,  601 
indications  for,  511 
Sanatoriums,  505 

causes  of  failure  in,  510 

cures  in,  441 

discipline  in,  463 

educational  value  of,  508 

gains  in  weight  in,  210 

incipient  phthisis  in,  601 

non-tuberculous  cases  in,  144,  365 

prophylactic  value  of,  509 

scope  of,  505 

statistics  of,  508,  509  _ 

tubercuhn  treatment  in,  538 

usefulness  of,  506 
Sausages,  tubercle  bacilli  in,  20 
Savages,  tuberculosis  among,  61 
Schmorl's  groove,  85 
Sclerosis,  125 
Scohosis,  218 
Scrofula,  434 

antagonistic  to  phthisis,  112 
Sea  climates,  501 
Selfishness,  236 
Semen,  tubercle  bacilU  in,  80 
Senile  phthisis,  394 
Servants,  domestic,  447 
Sex  frequency  of  laryngeal  tuberculosis, 
408 

in  hemoptysis,  192 

influence  of,  on  mortaUty,  69 
on  prognosis,  476 
Sexual  distiu-bances,  238 

excesses,  240 

irritability,  240 
Shoulder,  pains  in,  233 
Silica,  dangers  of,  99 
Sirolin,  531 
Skiagraphy,  290 

in  advanced  phthisis,  298 

apices  in,  291,  295 

in  bronchial  adenopathy,  388 

cavities  in,  299 

in  incipient  tuberculosis,  295 

sources  of  error  in,  297 
Skin,  212,  243 

infection  of,  38 

susceptibility  of,  23 

tuberculosis  of,  28 


Sleep,  237 

Smegma  baciUus,  25,  27,  161 
Smith's  sign,  387 
Smoking,  466,  549,  563 
Softening,  125 
Soil,  acid-fast  bacilli  in,  26 
Somnolence,  238 
"Song  cure,"  442 
Spermatogenic  infection,  81 
Spes  phthisica,  237 
Specific  treatment,  538 
Specifics,  lack  of,  525,  538,  542 
Sputum  in  abortive  tuberculosis,  367 
in  advanced  phthisis,  333 
albumin  in,  164 
chemical  examination  of,  164 
in  coUapse  induration,  326 
collection  of  specimen,  158 
cytology  of,  164     _ 
dangers  of  swallowing  of,  549 
diagnostic  value  of,  27 
disposal  of,  455 
effects  of  artificial  pneumothorax  on, 

584         - 
elastic  tissue  in,  336 
examination  by  antiformin,  160 
fetid,  363 

in  gangrene  of  limg,  401 
infectivity  of,  455 
inoculation  of,  162 
macroscopic  appearance,  156 
microscopic  examination,  159 
number  of  bacUli  in,  62 
niunmular,  157 
odor,  157 

in  pneumokoniosis,  327 
streaky,  187,  189,  194,  198 
swallowed,  207 
tubercle  bacilli  in,  20 
Stages  of  phthisis,  prognosis  during,  424 
Stenosis,  mitral  and  phthisis,  92 
pulmonary,  93 

of  upper  thoracic  aperture,  84 
Stigmata  of  phthisis,  142 
Stomach,  dilatation  of,  153,  206 

tuberculous  ulceration  of,  206 
Street-sweepers,    rarity   of   tuberculosis 

among,  98 
Streptothi'ix,  acid-fast,  26 
Styracol,  530 
Succussion  sound,  405 
Suggestion,  236 

amenability  to,  442,  445 
in  climatic  treatment,  494 
in  tuberculin  treatment,  443 
vulnerability  to,  442 
Superalimentation,  514 
dangers  of,  522 
hemoptysis  and,  193 
necessary  precautions  in,  517 
Superinfection,  106 
Susceptibility,  76 
Sweat,  172 

effects  of,  213 
Symptomatic  treatment,  548 


INDEX  OF  SUBJECTS 


Symptomatology,  importance  of,  149 
Syphilis,  fibroid  phthisis  and,  356 
hemoptysis  in,  196 
of  lungs,  118,  329 
phthisis  and,  105,  147,  435 
tuberculous  reaction  and,  33 


Tachycardia,  220,  328 

in  abortive  tuberculosis,  367 

causes  of,  221 

in  high  altitude,  500 

in  incipient  phthisis,  311 

paroxysmal,  221 

treatment  of,  563 
Tailors,  tuberculosis  among,  98 
Temperature  in  children,  169,  377 

during  hemoptysis,  191,  201 

effects  of  work  on,  477 

frequency  of  taking,  168 

instability  of,  172 

normal,  169 

subnormal,  169,  179 

technic  of  taking,  167 

types  of,  in  phthisis,  176 
Tents,  484,  485 
Thallium,  526 
Thermometers,  166 
Thiocol,  530 

Thoracic  asymmetry,  248 
Thoracocentesis,  577,  613,  615 
Thorax,  deformities  of,  84 

infantile,  85 

normal,  245 
Thrombosis,  230,  418 

of  femoral  vein,  419 

of  jugular  vein,  420 
Thymus,  enlargement  of,  385 
Thyroid,  244 

enlargement  of,  311 
Timothy-grass  bacillus,  25,  27,  161 
Tobacco,  use  of,  466 
Tongue,  tuberculous  ulceration  of,  470 
Tonsillitis,  epidemics  of,  553 
Tonsils,  90 

tubercle  bacilli  in,  26 
Toxemia,  237 

effects  of,  442 

psychic  effects  of,  237 
Toxin,  tuberculous,  29,  30 

hypersensitiveness  to,  320 
Trachea,  displacement  of,  344 
Tracheal  tone,  Williams's,  339 
Tracheophony,  386 
Transmission,  germinal,  79 
Traumatism  and  tuberculosis.  101 
Treatment  of  acute  phthisis,  608 
of  advanced  phthisis,  602 
of  arrested  cases,  605 
climatic,  492 
of  complications,  613 
of  convalescents,  605 
criteria  for,  440 


Treatment,  dietetic,  513 

of  aged  patients,  611 
of  children,  609 
economic  aspects  of,  463 
of  fibroid  phthisis,  606 
of  incipient  phthisis,  601 
indications  for,  438,  445 
individualization  of,  510 
institutional,  505 
medicinal,  525,  603 
open-air,  480 

of  children,  608 
operative,  568 
psychic  influences  on,  442 
specific,  538 

of  children,  610 
symptomatic,  548 
tuberculin,  538 

utility  of,  545 
of  tuberculosis  in  aged,  611 
in  children,  609 
during  the  menopause,  612 
Tubercle  bacilli,  17 

in  abortive  tuberculosis,  421 
effects  of  cold  on,  20 

of  dessication  on,  20 
of  heat  on,  20 
of  light  on,  20 
in  fetus,  80 
ingestion  of,  46 
inhalation  of,  421 
in  ovary,  79 
in  placenta,  78,  81 
in  semen,  80 
in  sputum,  159,  162,  316 

diagnostic  value  of,  316 
in  thrombi,  418 
types  of,  22,  27,  301 
ubiquity  of,  52 
in  urine,  421 
virulence  of,  22,  27 
Tubercles,  caseation  of,  123 
calcification  of,  125 
sclerosis,  125 
softening  of,  125 
structure  of,  121 
Tuberculides,  38 
Tuberculin,  30 

action  of,  31,  540 
chemistry  of,  31 
effects  on  blood-pressure,  22 
hypersensitiveness  to,  317 
method  of  preparation,  30 
new,  539 
old,  539 

reaction  in  children,  58 
cutaneous,  318 

signs  of,  319 
focal,  322 
local,  322 
symptoms  of,  319 
specificity  of,  32,  320,  323 
tests,  317 

in  children,  390 
clinical  value  of,  322 


INDEX  OF  SUBJECTS 


639 


Tuberculin  tests,  conjunctival,  321 

contra-indications,  324 

cutaneous,  318 

in  infants,  374 

dangers  of,  324 

diagnostic  value  of,  323 

Moro,  321 

ophthalmoreaction,  321 

percutaneous,  321 

quantitative  cutaneous,  321 

specificity  of,  320,  323 

subcutaneous,  321 
treatment,  538 

administration,  543 

clinical  evidence  of  ineflficacy, 
542 

dangers  from,  546 

dilutions,  543 

dosage,  539,  543 

hemoptysis  during,  547 

inefficacy  in  animals,  541 

lack  of  statistics,  543 

psychic  effect,  236,  443,  545 

results  from  545 

tolerance,  540 
varieties  of,  538 
Tuberculolysin,  31,  540 
Tuberculosis,  acute  miliary,  34 
among  primitive  peoples,  61 
apyretic,  181 
city  life  and,  72 
congenital,  81 
in  domestic  animals,  28 
effects  of  campaign  against,  72 
experimental,  21 
generalized,  28 
geographical  distribution,  63 
housing  conditions  and,  66 
incidence  of,  67 

according  to  age,  67,  369 

among  the  living,  58 

at  autopsies,  53 
mortality  from,  63 
occupation  and,  69 
overcrowding  and,  66 
poverty  and,  58,  60,  66 
pulmonary,  in  animals,  44 
in  rural  populations,  61,  64 
vurrucosa  cutis,  38 
on  virgin  soil,  113 
vs.  phthisis,  103 
Turtle  bacilli,  25 
culture,  443 
Tying  the  extremities  in  hemoptysis,  558 
Tympany  over  cavities,  338 

in  pneumothorax,  585 
Typhoid  fever,  95 


Ulcers,  intestinal,  141 
Urbanization  and  tuberculosis,  72,  74 
Uremia,  230 

Urine,  tubercle  bacilli  in,  421 
Urochromogen  reaction,  432 
Urogenital  tract,  tuberculosis  in,  420 


Vas  deferens,  tuberculosis  of,  421 

Veins,  enlarged  on  chest,  244,  383 

Venesection  in  hemoptysis,  561 

Ventilation,  482 

Virulence  of  tubercle  bacilli,  20 

Visceral  displacements,  362 

Voice  sounds,  287 

Vocal  cords,  paresis  of,  410 

Vomiting  after  cough,  152 

of  blood,  198 

during  advanced  phthisis,  207 

in  meningitis,  416 

in  peritonitis,  415 
Voyages,  sea,  501 


W 

Wages  and  tuberculosis,  66,  70,  100 
Water,  tubercle  bacilli  in,  26 
Wart,  butcher's,  113 

pathologist's,  113 
Weight,  209 

diet  and,  515 

gains  in,  210 

of  healthy  children,  376 
Whispered  voice,  288 

in  healthy  persons,  289 
in  incipient  phthisis,  314 
Williams's  tracheal  tone,  339 
Wintrich's  phenomenon,  339,  405 


X-RAYS,  290 


ZiEHL-NiELSEN  stain,  159 
Zomotherapy,  518 


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